{"hospital_name":"Mercyhealth Hospital & Medical Center - Walworth","last_updated_on":"2026-03-01","version":"3.0.0","location_name":["Mercyhealth Hospital & Medical Center - Walworth"],"hospital_address":["N2950 State Road 67, Lake Geneva, WI 53147"],"license_information":{"license_number":"1062","state":"WI"},"type_2_npi":["1699728550"],"attestation":{"attestation":"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.","confirm_attestation":true,"attester_name":"Bradley Olson"},"modifier_information":[{"description":"Reduced Services","code":"52","modifier_payer_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Advantage Medicare Managed Care - 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":62997.51,"10th_percentile":62997.51,"90th_percentile":62997.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. 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Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":19872.45,"maximum":26270.45,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":26270.45},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21071.27},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19872.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22183.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Hemorrhage With Mcc","code_information":[{"code":"377","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39302.0,"maximum":51955.42,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51955.42},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41672.92},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39302.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43872.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Hemorrhage With Cc","code_information":[{"code":"378","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21085.05,"maximum":27873.46,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27873.46},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22357.02},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21085.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23536.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Hemorrhage Without Cc/Mcc","code_information":[{"code":"379","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13553.6,"maximum":17917.23,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":17917.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14371.23},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13553.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15129.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complicated Peptic Ulcer With Mcc","code_information":[{"code":"380","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":42187.3,"maximum":55769.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":55769.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44732.27},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42187.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47092.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":23295.25,"maximum":30795.24,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30795.24},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24700.55},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23295.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26004.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complicated Peptic Ulcer Without Cc/Mcc","code_information":[{"code":"382","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17212.9,"maximum":22754.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22754.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18251.28},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17212.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19214.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uncomplicated Peptic Ulcer With Mcc","code_information":[{"code":"383","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29685.05,"maximum":39242.26,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39242.26},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31475.82},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29685.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33136.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uncomplicated Peptic Ulcer Without Mcc","code_information":[{"code":"384","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18378.2,"maximum":24295.13,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24295.13},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19486.88},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18378.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20515.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammatory Bowel Disease With Mcc","code_information":[{"code":"385","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34019.45,"maximum":44972.13,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":44972.13},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36071.69},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34019.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37975.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":15639.1,"maximum":20674.16,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20674.16},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16582.54},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15639.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17457.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":21951.5,"maximum":29018.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29018.86},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23275.74},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21951.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24504.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":22881.43,"10th_percentile":22881.43,"90th_percentile":22881.43,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3621.12,"10th_percentile":3621.12,"90th_percentile":3621.12,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","code_information":[{"code":"371","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38121.65,"maximum":50395.05,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":50395.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40421.36},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38121.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42554.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Esophageal Disorders Without Cc/Mcc","code_information":[{"code":"370","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15067.2,"maximum":19918.14,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19918.14},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15976.14},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15067.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16819.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Esophageal Disorders With Cc","code_information":[{"code":"369","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21504.3,"maximum":28427.68,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28427.68},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22801.56},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21504.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24004.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Esophageal Disorders With Mcc","code_information":[{"code":"368","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34225.85,"maximum":45244.98,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":45244.98},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36290.54},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34225.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38205.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":51907.45,"maximum":68619.23,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":68619.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55038.8},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51907.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57943.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":73929.9,"maximum":97731.89,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":97731.89},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":78389.76},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73929.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82526.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":30054.85,"maximum":39731.11,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39731.11},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31867.93},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30054.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33549.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System O.R. Procedures With Cc","code_information":[{"code":"357","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":49998.25,"maximum":66095.36,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":66095.36},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53014.42},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49998.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55812.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System O.R. Procedures With Mcc","code_information":[{"code":"356","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":94445.2,"maximum":124852.16,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":124852.16},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":100142.66},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94445.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105427.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","code_information":[{"code":"355","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28917.5,"maximum":38227.59,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":38227.59},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30661.97},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28917.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32280.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hernia Procedures Except Inguinal And Femoral With Cc","code_information":[{"code":"354","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36171.6,"maximum":47817.17,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":47817.17},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38353.67},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36171.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40377.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hernia Procedures Except Inguinal And Femoral With Mcc","code_information":[{"code":"353","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":62393.0,"maximum":82480.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":82480.64},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":66156.89},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62393.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69648.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","code_information":[{"code":"352","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25107.7,"maximum":33191.21,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":33191.21},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26622.34},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25107.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28027.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inguinal And Femoral Hernia Procedures With Cc","code_information":[{"code":"351","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32776.75,"maximum":43329.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43329.34},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34754.03},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32776.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36588.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":18720.82,"10th_percentile":18720.82,"90th_percentile":18720.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inguinal And Femoral Hernia Procedures With Mcc","code_information":[{"code":"350","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":53575.85,"maximum":70824.78,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":70824.78},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":56807.84},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53575.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59805.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Anal And Stomal Procedures Without Cc/Mcc","code_information":[{"code":"349","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18717.9,"maximum":24744.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24744.19},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19847.07},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18717.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20894.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Transplant Or Implant Of Heart Assist System With Mcc","code_information":[{"code":"001","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":602513.85,"maximum":796495.29,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":796495.29},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":638860.85},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":602513.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":672573.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Transplant Or Implant Of Heart Assist System Without Mcc","code_information":[{"code":"002","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":243633.7,"maximum":322072.42,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":322072.42},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":258331.04},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":243633.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":271963.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":456341.8,"maximum":603262.63,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":603262.63},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":483870.88},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":456341.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":509404.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":297805.1,"maximum":393684.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":393684.49},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":315770.37},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":297805.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":332433.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":221675.75,"maximum":293045.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":293045.03},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":235048.47},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":221675.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":247452.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":99695.5,"maximum":131792.81,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":131792.81},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":105709.69},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99695.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":111288.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":278429.3,"maximum":368070.58,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":368070.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":295225.71},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":278429.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":310804.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simultaneous Pancreas And Kidney Transplant","code_information":[{"code":"008","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":120498.9,"maximum":159293.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":159293.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":127768.07},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120498.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134510.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Allogeneic Bone Marrow Transplant","code_information":[{"code":"014","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":258384.85,"maximum":341572.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":341572.75},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":273972.07},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":258384.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":288429.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Autologous Bone Marrow Transplant With Cc/Mcc","code_information":[{"code":"016","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":127488.55,"maximum":168533.93,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":168533.93},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":135179.37},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":127488.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142312.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Autologous Bone Marrow Transplant Without Cc/Mcc","code_information":[{"code":"017","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":116794.45,"maximum":154396.83,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":154396.83},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":123840.14},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116794.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130375.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Disorders And Injuries Without Cc/Mcc","code_information":[{"code":"053","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21052.8,"maximum":27830.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27830.82},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22322.82},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21052.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23500.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Disorders And Injuries With Cc/Mcc","code_information":[{"code":"052","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38942.95,"maximum":51480.77,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51480.77},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41292.21},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38942.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43471.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","code_information":[{"code":"042","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37145.55,"maximum":49104.69,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":49104.69},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39386.38},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37145.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41464.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":47272.05,"maximum":62491.45,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":62491.45},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50123.76},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47272.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52768.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17116.64,"10th_percentile":17116.64,"90th_percentile":17116.64,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","code_information":[{"code":"040","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":83015.8,"maximum":109743.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":109743.03},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":88023.78},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":83015.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92668.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extracranial Procedures Without Cc/Mcc","code_information":[{"code":"039","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25273.25,"maximum":33410.06,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":33410.06},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26797.87},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25273.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28212.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extracranial Procedures With Cc","code_information":[{"code":"038","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34885.9,"maximum":46117.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":46117.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36990.41},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34885.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38942.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extracranial Procedures With Mcc","code_information":[{"code":"037","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":70780.15,"maximum":93568.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":93568.07},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":75050.0},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70780.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79010.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Carotid Artery Stent Procedures Without Cc/Mcc","code_information":[{"code":"036","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":41770.2,"maximum":55218.26,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":55218.26},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44290.01},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41770.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46627.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Carotid Artery Stent Procedures With Cc","code_information":[{"code":"035","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":51395.75,"maximum":67942.79,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":67942.79},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":54496.23},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51395.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57372.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Carotid Artery Stent Procedures With Mcc","code_information":[{"code":"034","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":83220.05,"maximum":110013.04,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":110013.04},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":88240.35},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":83220.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92896.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ventricular Shunt Procedures Without Cc/Mcc","code_information":[{"code":"033","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35752.35,"maximum":47262.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":47262.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37909.13},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35752.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39909.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ventricular Shunt Procedures With Cc","code_information":[{"code":"032","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45816.5,"maximum":60567.28,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":60567.28},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48580.41},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45816.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51144.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":96330.75,"maximum":127344.77,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":127344.77},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":102141.96},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96330.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107532.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":47196.8,"maximum":62391.97,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":62391.97},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50043.97},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47196.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52684.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":73349.4,"maximum":96964.5,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":96964.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":77774.25},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73349.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81878.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Procedures With Mcc","code_information":[{"code":"028","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":129178.45,"maximum":170767.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":170767.9},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":136971.22},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":129178.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144199.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":54242.35,"maximum":71705.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":71705.86},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":57514.55},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54242.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60549.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":66847.8,"maximum":88369.68,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":88369.68},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":70880.43},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66847.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74620.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":97754.05,"maximum":129226.31,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":129226.31},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":103651.12},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97754.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":109120.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":84105.85,"maximum":111184.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":111184.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":89179.58},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84105.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93885.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":123201.45,"maximum":162866.59,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":162866.59},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":130633.65},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123201.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137527.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":68314.1,"maximum":90308.06,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":90308.06},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":72435.19},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68314.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76257.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":113816.7,"maximum":150460.38,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":150460.38},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":120682.76},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113816.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":127051.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","code_information":[{"code":"020","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":169179.2,"maximum":223647.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":223647.03},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":179385.03},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":169179.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":188851.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","code_information":[{"code":"019","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":153393.9,"maximum":202779.6,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":202779.6},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":162647.48},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":153393.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":171230.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","code_information":[{"code":"018","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":928430.2,"maximum":1227341.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":1227341.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":984438.29},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":928430.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1036387.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":16980.7,"maximum":22447.7,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22447.7},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18005.07},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16980.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18955.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","code_information":[{"code":"422","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30089.25,"maximum":39776.59,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39776.59},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31904.4},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30089.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33588.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","code_information":[{"code":"423","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":89289.5,"maximum":118036.57,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":118036.57},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":94675.94},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89289.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99672.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","code_information":[{"code":"424","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":47039.85,"maximum":62184.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":62184.49},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49877.56},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47039.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52509.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":32256.45,"maximum":42641.53,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42641.53},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34202.34},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32256.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36007.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","code_information":[{"code":"426","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":236955.8,"maximum":313244.55,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":313244.55},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":251250.3},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":236955.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":264508.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Anal And Stomal Procedures With Cc","code_information":[{"code":"348","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28139.2,"maximum":37198.71,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":37198.71},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29836.71},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28139.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31411.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Anal And Stomal Procedures With Mcc","code_information":[{"code":"347","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":49355.4,"maximum":65245.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":65245.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":52332.79},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49355.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55094.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Small And Large Bowel Procedures Without Cc/Mcc","code_information":[{"code":"346","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25503.3,"maximum":33714.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":33714.18},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27041.8},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25503.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28468.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Small And Large Bowel Procedures With Cc","code_information":[{"code":"345","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32351.05,"maximum":42766.58,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42766.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34302.65},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32351.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36112.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":55530.2,"maximum":73408.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":73408.34},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":58880.09},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55530.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61987.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":33002.5,"maximum":43627.77,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43627.77},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34993.4},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33002.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36840.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peritoneal Adhesiolysis With Cc","code_information":[{"code":"336","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45337.05,"maximum":59933.47,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":59933.47},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48072.03},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45337.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50608.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":13556.66,"10th_percentile":13556.66,"90th_percentile":13556.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peritoneal Adhesiolysis With Mcc","code_information":[{"code":"335","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":76774.35,"maximum":101492.12,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":101492.12},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":81405.81},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76774.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85701.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rectal Resection Without Cc/Mcc","code_information":[{"code":"334","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35214.85,"maximum":46552.39,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":46552.39},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37339.21},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35214.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39309.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":50357.3,"maximum":66570.01,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":66570.01},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53395.13},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50357.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56212.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":77845.05,"maximum":102907.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":102907.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":82541.1},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77845.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86896.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":36182.35,"maximum":47831.38,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":47831.38},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38365.07},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36182.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40389.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":43363.52,"10th_percentile":43363.52,"90th_percentile":43363.52,"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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":51010.31,"10th_percentile":51010.31,"90th_percentile":51010.31,"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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":15164.48,"10th_percentile":15164.48,"90th_percentile":15164.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":51539.8,"maximum":68133.22,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":68133.22},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":54648.97},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51539.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57532.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":36741.23,"10th_percentile":36741.23,"90th_percentile":36741.23,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":12893.32,"10th_percentile":12893.32,"90th_percentile":12893.32,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":98824.75,"maximum":130641.72,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":130641.72},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":104786.41},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98824.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":110316.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":34449.45,"maximum":45540.57,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":45540.57},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36527.63},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34449.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38455.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":52550.3,"maximum":69469.05,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":69469.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55720.43},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52550.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58660.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare 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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":107229.1,"maximum":141751.88,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":141751.88},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":113697.76},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":107229.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":119697.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":39543.78,"10th_percentile":39543.78,"90th_percentile":39543.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":69023.6,"maximum":91245.99,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":91245.99},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":73187.49},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69023.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77049.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","code_information":[{"code":"324","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":67746.5,"maximum":89557.72,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":89557.72},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":71833.35},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67746.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75624.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":40253.06,"10th_percentile":39062.0,"90th_percentile":45896.49,"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":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","code_information":[{"code":"323","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":93039.1,"maximum":122993.36,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":122993.36},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":98651.74},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93039.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103857.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","code_information":[{"code":"322","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37904.5,"maximum":50107.99,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":50107.99},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40191.11},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37904.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42312.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":58497.2,"maximum":77330.58,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":77330.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":62026.08},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58497.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65299.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":51713.95,"maximum":68363.44,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":68363.44},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":54833.62},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51713.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57727.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":95952.35,"maximum":126844.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":126844.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":101740.73},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95952.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107109.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":52077.3,"maximum":68843.77,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":68843.77},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55218.89},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52077.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58132.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":143759.75,"maximum":190043.7,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":190043.7},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":152432.14},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143759.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":160476.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":14665.15,"maximum":19386.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19386.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15549.83},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14665.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16370.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":20710.95,"maximum":27378.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27378.91},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21960.35},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20710.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23119.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System Diagnoses With Mcc","code_information":[{"code":"314","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":44831.8,"maximum":59265.55,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":59265.55},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47536.3},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44831.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50044.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chest Pain","code_information":[{"code":"313","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15480.0,"maximum":20463.84,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20463.84},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16413.84},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15480.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17280.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"1 through 10","median_amount":37274.31,"10th_percentile":37274.31,"90th_percentile":37274.31,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","code_information":[{"code":"427","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":155199.9,"maximum":205167.05,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":205167.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":164562.42},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":155199.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":173246.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","code_information":[{"code":"428","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":120873.0,"maximum":159788.48,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":159788.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":128164.73},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120873.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134928.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","code_information":[{"code":"429","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":193706.4,"maximum":256070.85,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":256070.85},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":205391.85},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":193706.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":216230.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","code_information":[{"code":"430","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":123992.65,"maximum":163912.52,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":163912.52},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":131472.58},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123992.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":138410.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cirrhosis And Alcoholic Hepatitis With Mcc","code_information":[{"code":"432","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":42316.3,"maximum":55940.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":55940.18},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44869.06},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42316.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47236.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":15164.48,"10th_percentile":15164.48,"90th_percentile":15164.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cirrhosis And Alcoholic Hepatitis With Cc","code_information":[{"code":"433","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22708.3,"maximum":30019.32,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30019.32},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24078.19},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22708.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25348.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":23615.84,"10th_percentile":23615.84,"90th_percentile":23615.84,"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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":1748.33,"10th_percentile":1748.33,"90th_percentile":1748.33,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","code_information":[{"code":"434","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15318.75,"maximum":20250.68,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20250.68},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16242.86},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15318.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17100.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","code_information":[{"code":"435","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39489.05,"maximum":52202.69,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":52202.69},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41871.25},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39489.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44080.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":24318.65,"maximum":32148.12,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":32148.12},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25785.69},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24318.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27146.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":18345.95,"maximum":24252.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24252.49},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19452.68},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18345.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20479.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":35049.3,"maximum":46333.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":46333.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37163.67},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35049.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39124.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":18085.8,"maximum":23908.59,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23908.59},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19176.84},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18085.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20188.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":30156.07,"10th_percentile":30156.07,"90th_percentile":30156.07,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":13360.1,"maximum":17661.43,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":17661.43},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14166.06},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13360.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14913.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":16973.07,"10th_percentile":16973.07,"90th_percentile":16973.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":13328.33,"10th_percentile":13328.33,"90th_percentile":13328.33,"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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":38586.05,"maximum":51008.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51008.96},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40913.78},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38586.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43072.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":20753.95,"maximum":27435.76,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27435.76},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22005.94},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20753.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23167.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":15043.55,"maximum":19886.87,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19886.87},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15951.06},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15043.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16792.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":35924.35,"maximum":47490.32,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":47490.32},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38091.51},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35924.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40101.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":23529.6,"maximum":31105.04,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":31105.04},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24949.04},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23529.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26265.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":17786.95,"maximum":23513.52,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23513.52},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18859.96},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17786.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19855.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":31751.2,"maximum":41973.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":41973.61},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33666.61},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31751.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35443.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3543.86,"10th_percentile":3543.86,"90th_percentile":3543.86,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":14647.95,"maximum":19363.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19363.91},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15531.6},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14647.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16351.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammatory Bowel Disease With Cc","code_information":[{"code":"386","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20990.45,"maximum":27748.4,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27748.4},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22256.71},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20990.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23431.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":18739.4,"maximum":24772.62,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24772.62},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19869.87},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18739.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20918.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":15090.85,"maximum":19949.4,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19949.4},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16001.21},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15090.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16845.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":12171.15,"maximum":16089.69,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":16089.69},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12905.38},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12171.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13586.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrhythmia And Conduction Disorders With Cc","code_information":[{"code":"309","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15817.55,"maximum":20910.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20910.07},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16771.75},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15817.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17656.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":13704.79,"10th_percentile":13704.79,"90th_percentile":13704.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":11036.59,"10th_percentile":11036.59,"90th_percentile":11036.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":35649.39,"10th_percentile":35649.39,"90th_percentile":35649.39,"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":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3405.18,"10th_percentile":3405.18,"90th_percentile":3405.18,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","code_information":[{"code":"308","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25886.0,"maximum":34220.09,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":34220.09},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27447.59},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25886.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28896.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3747.94,"10th_percentile":3747.94,"90th_percentile":3747.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":12623.32,"10th_percentile":12623.32,"90th_percentile":12623.32,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":19633.8,"maximum":25954.97,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25954.97},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20818.22},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19633.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21916.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":33879.7,"maximum":44787.39,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":44787.39},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35923.51},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33879.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37819.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":16234.65,"maximum":21461.45,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":21461.45},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17214.01},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16234.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18122.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":43791.98,"10th_percentile":43791.98,"90th_percentile":43791.98,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":25585.0,"maximum":33822.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":33822.18},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27128.43},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25585.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28560.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":14473.8,"maximum":19133.69,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19133.69},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15346.94},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14473.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16156.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":15164.48,"10th_percentile":15164.48,"90th_percentile":15164.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Atherosclerosis With Mcc","code_information":[{"code":"302","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25726.9,"maximum":34009.77,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":34009.77},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27278.89},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25726.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28718.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral Vascular Disorders Without Cc/Mcc","code_information":[{"code":"301","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15473.55,"maximum":20455.31,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20455.31},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16407.0},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15473.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17272.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral Vascular Disorders With Cc","code_information":[{"code":"300","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22951.25,"maximum":30340.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30340.49},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24335.8},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22951.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25620.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral Vascular Disorders With Mcc","code_information":[{"code":"299","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35103.05,"maximum":46404.6,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":46404.6},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37220.66},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35103.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39184.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrest, Unexplained Without Cc/Mcc","code_information":[{"code":"298","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9784.65,"maximum":12934.85,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":12934.85},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":10374.91},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9784.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10922.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrest, Unexplained With Cc","code_information":[{"code":"297","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13631.0,"maximum":18019.55,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":18019.55},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14453.3},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13631.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15216.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":33580.85,"maximum":44392.32,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":44392.32},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35606.63},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33580.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37485.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":12169.0,"maximum":16086.85,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":16086.85},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12903.1},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12169.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13584.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":18631.34,"10th_percentile":18631.34,"90th_percentile":18631.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":18253.5,"maximum":24130.28,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24130.28},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19354.65},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18253.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20376.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":13783.19,"10th_percentile":13783.19,"90th_percentile":13783.19,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":27601.7,"maximum":36488.16,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":36488.16},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29266.79},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27601.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30811.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":10306.85,"10th_percentile":5788.12,"90th_percentile":26007.08,"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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":21706.84,"10th_percentile":21706.84,"90th_percentile":21706.84,"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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"1 through 10","median_amount":16331.88,"10th_percentile":16331.88,"90th_percentile":16331.88,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":18394.32,"10th_percentile":18394.32,"90th_percentile":18394.32,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":7582.24,"10th_percentile":7582.24,"90th_percentile":7582.24,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":7496.66,"10th_percentile":7496.66,"90th_percentile":14961.32,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":19988.55,"maximum":26423.93,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":26423.93},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21194.37},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19988.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22312.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":36698.35,"maximum":48513.51,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":48513.51},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38912.2},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36698.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40965.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":58183.3,"maximum":76915.62,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":76915.62},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":61693.24},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58183.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64948.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":23007.15,"maximum":30414.38,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30414.38},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24395.07},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23007.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25682.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":47575.2,"maximum":62892.2,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":62892.2},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50445.2},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47575.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53107.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":12876.35,"maximum":17021.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":17021.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13653.12},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12876.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14373.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Expired With Cc","code_information":[{"code":"284","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14882.3,"maximum":19673.71,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19673.71},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15780.08},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14882.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16612.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Expired With Mcc","code_information":[{"code":"283","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":42587.2,"maximum":56298.3,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":56298.3},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45156.3},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42587.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47539.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","code_information":[{"code":"282","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15546.65,"maximum":20551.95,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20551.95},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16484.51},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15546.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17354.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":10689.75,"10th_percentile":10689.75,"90th_percentile":10689.75,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":23187.69,"10th_percentile":23187.69,"90th_percentile":23187.69,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Discharged Alive With Cc","code_information":[{"code":"281","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19760.65,"maximum":26122.66,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":26122.66},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20952.72},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19760.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22058.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Nervous System Neoplasms With Mcc","code_information":[{"code":"054","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32828.35,"maximum":43397.55,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43397.55},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34808.74},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32828.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36645.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":21921.4,"maximum":28979.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28979.07},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23243.82},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21921.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24470.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":14971.16,"10th_percentile":14971.16,"90th_percentile":14971.16,"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":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Degenerative Nervous System Disorders With Mcc","code_information":[{"code":"056","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":49946.65,"maximum":66027.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":66027.15},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":52959.71},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49946.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55754.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":27855.4,"maximum":36823.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":36823.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29535.79},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27855.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31094.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Sclerosis And Cerebellar Ataxia With Mcc","code_information":[{"code":"058","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36754.25,"maximum":48587.41,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":48587.41},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38971.47},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36754.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41028.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Sclerosis And Cerebellar Ataxia With Cc","code_information":[{"code":"059","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26679.35,"maximum":35268.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":35268.86},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28288.8},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26679.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29781.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":37779.8,"maximum":49943.14,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":49943.14},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40058.89},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37779.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42172.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":30181.7,"maximum":39898.8,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39898.8},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32002.43},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30181.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33691.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":43236.5,"maximum":57156.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":57156.64},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45844.77},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43236.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48264.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":31593.31,"10th_percentile":31593.31,"90th_percentile":31593.31,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":7496.66,"10th_percentile":7496.66,"90th_percentile":7496.66,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":21721.45,"maximum":28714.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28714.75},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23031.81},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21721.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24247.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":7430.6,"10th_percentile":7430.6,"90th_percentile":7430.6,"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 Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":18394.32,"10th_percentile":18394.32,"90th_percentile":18394.32,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":14714.6,"maximum":19452.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19452.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15602.27},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14714.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16425.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":7582.24,"10th_percentile":7582.24,"90th_percentile":7582.24,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":31577.05,"maximum":41743.39,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":41743.39},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33481.95},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31577.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35248.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":18584.6,"maximum":24567.98,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24567.98},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19705.73},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18584.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20745.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":18605.99,"10th_percentile":18605.99,"90th_percentile":18605.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":18522.08,"10th_percentile":18522.08,"90th_percentile":18522.08,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":17174.2,"maximum":22703.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22703.49},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18210.24},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17174.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19171.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":35793.2,"maximum":47316.95,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":47316.95},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37952.45},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35793.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39955.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":22059.0,"maximum":29160.97,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29160.97},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23389.72},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22059.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24624.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Discharged Alive With Mcc","code_information":[{"code":"280","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34488.15,"maximum":45591.73,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":45591.73},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36568.67},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34488.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38498.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","code_information":[{"code":"279","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":77537.6,"maximum":102501.1,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":102501.1},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":82215.1},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77537.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86553.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","code_information":[{"code":"278","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":119673.3,"maximum":158202.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":158202.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":126892.66},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":119673.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":133588.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous And Other Intracardiac Procedures Without Mcc","code_information":[{"code":"274","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":70771.55,"maximum":93556.7,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":93556.7},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":75040.88},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70771.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79000.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous And Other Intracardiac Procedures With Mcc","code_information":[{"code":"273","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":88698.25,"maximum":117254.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":117254.96},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":94049.02},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":88698.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99012.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":54889.5,"maximum":72561.37,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":72561.37},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":58200.74},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54889.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61272.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":76460.45,"maximum":101077.16,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":101077.16},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":81072.97},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76460.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85351.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Major Cardiovascular Procedures With Mcc","code_information":[{"code":"270","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":113440.45,"maximum":149963.0,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":149963.0},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":120283.81},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113440.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126631.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","code_information":[{"code":"269","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":90798.8,"maximum":120031.79,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":120031.79},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":96276.29},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90798.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101356.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":147874.85,"maximum":195483.67,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":195483.67},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":156795.49},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":147874.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":165069.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":102357.2,"maximum":135311.46,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":135311.46},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":108531.96},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102357.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114259.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":131760.6,"maximum":174181.38,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":174181.38},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":139709.13},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":131760.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":147081.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":77791.3,"maximum":102836.48,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":102836.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":82484.11},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77791.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86836.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":71822.9,"maximum":94946.53,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":94946.53},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":76155.66},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71822.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80174.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":65734.1,"maximum":86897.42,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":86897.42},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":69699.55},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65734.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73377.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":28122.34,"10th_percentile":28122.34,"90th_percentile":28122.34,"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":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","code_information":[{"code":"262","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35042.85,"maximum":46325.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":46325.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37156.83},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35042.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39117.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Revision Except Device Replacement With Cc","code_information":[{"code":"261","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":40645.75,"maximum":53731.79,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":53731.79},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43097.73},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40645.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45372.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Revision Except Device Replacement With Mcc","code_information":[{"code":"260","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":69935.2,"maximum":92451.08,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":92451.08},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":74154.08},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69935.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78067.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare 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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Device Replacement Without Mcc","code_information":[{"code":"259","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":43475.15,"maximum":57472.13,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":57472.13},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":46097.81},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43475.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48530.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Device Replacement With Mcc","code_information":[{"code":"258","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":67555.15,"maximum":89304.77,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":89304.77},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":71630.45},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67555.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75410.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":36504.85,"maximum":48257.71,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":48257.71},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38707.03},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36504.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40749.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":57994.1,"maximum":76665.5,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":76665.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":61492.63},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57994.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64737.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare 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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":38306.55,"maximum":50639.48,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":50639.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40617.41},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38306.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42760.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":55805.4,"maximum":73772.14,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":73772.14},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":59171.89},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55805.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62294.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":74998.45,"maximum":99144.46,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":99144.46},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":79522.78},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74998.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83719.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":32131.75,"maximum":42476.68,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42476.68},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34070.12},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32131.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35868.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":16258.3,"maximum":21492.72,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":21492.72},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17239.09},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16258.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18148.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":34492.45,"maximum":45597.41,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":45597.41},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36573.23},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34492.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38503.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":22162.2,"maximum":29297.4,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29297.4},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23499.15},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22162.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24739.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":41226.25,"maximum":54499.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":54499.19},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43713.25},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41226.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46020.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":17741.8,"maximum":23453.83,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23453.83},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18812.08},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17741.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19804.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":38915.0,"maximum":51443.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51443.82},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41262.57},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38915.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43440.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":19255.4,"maximum":25454.74,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25454.74},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20416.99},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19255.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21494.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":49140.4,"maximum":64961.32,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":64961.32},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":52104.82},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49140.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54854.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":19154.3,"10th_percentile":19154.3,"90th_percentile":19154.3,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":30009.7,"maximum":39671.43,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39671.43},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31820.05},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30009.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33499.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":20549.7,"maximum":27165.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27165.75},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21789.37},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20549.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22939.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":48845.85,"maximum":64571.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":64571.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":51792.5},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48845.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54525.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma <1 Hour With Cc","code_information":[{"code":"086","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28008.05,"maximum":37025.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":37025.34},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29697.65},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28008.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31264.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","code_information":[{"code":"087","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19666.05,"maximum":25997.6,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25997.6},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20852.42},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19666.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21952.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concussion With Mcc","code_information":[{"code":"088","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29063.7,"maximum":38420.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":38420.86},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30816.98},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29063.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32443.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":23619.9,"maximum":31224.41,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":31224.41},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25044.78},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23619.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26366.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":17698.8,"maximum":23396.99,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23396.99},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18766.49},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17698.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19756.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of Nervous System With Mcc","code_information":[{"code":"091","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37758.3,"maximum":49914.72,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":49914.72},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40036.09},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37758.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42148.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of Nervous System With Cc","code_information":[{"code":"092","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21994.5,"maximum":29075.71,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29075.71},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23321.33},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21994.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24552.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of Nervous System Without Cc/Mcc","code_information":[{"code":"093","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17120.45,"maximum":22632.44,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22632.44},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18153.25},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17120.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19111.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bacterial And Tuberculous Infections Of Nervous System With Mcc","code_information":[{"code":"094","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":75667.1,"maximum":100028.39,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":100028.39},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":80231.76},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75667.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84465.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":55452.8,"maximum":73306.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":73306.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":58798.02},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55452.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61900.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":55452.8,"maximum":73306.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":73306.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":58798.02},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55452.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61900.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":77653.7,"maximum":102654.58,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":102654.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":82338.2},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77653.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86683.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":32569.69,"10th_percentile":32569.69,"90th_percentile":32569.69,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":49340.35,"maximum":65225.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":65225.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":52316.84},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49340.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55077.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":29291.6,"maximum":38722.13,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":38722.13},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31058.63},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29291.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32697.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":41641.2,"maximum":55047.73,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":55047.73},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44153.23},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41641.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46483.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare 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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":19405.9,"maximum":25653.7,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25653.7},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20576.57},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19405.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21662.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Headaches With Mcc","code_information":[{"code":"102","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24099.35,"maximum":31858.22,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":31858.22},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25553.16},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24099.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26901.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Headaches Without Mcc","code_information":[{"code":"103","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17980.45,"maximum":23769.32,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23769.32},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19065.13},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17980.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20071.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Orbital Procedures With Cc/Mcc","code_information":[{"code":"113","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":50548.65,"maximum":66822.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":66822.96},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53598.03},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50548.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56426.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","code_information":[{"code":"250","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":46923.75,"maximum":62031.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":62031.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49754.45},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46923.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52380.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aicd Generator Procedures","code_information":[{"code":"245","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":98091.6,"maximum":129672.53,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":129672.53},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":104009.03},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98091.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":109497.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","code_information":[{"code":"244","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38861.25,"maximum":51372.77,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51372.77},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41205.58},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38861.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43380.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Permanent Cardiac Pacemaker Implant With Cc","code_information":[{"code":"243","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45814.35,"maximum":60564.44,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":60564.44},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48578.13},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45814.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51141.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Permanent Cardiac Pacemaker Implant With Mcc","code_information":[{"code":"242","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":68645.2,"maximum":90745.76,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":90745.76},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":72786.26},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68645.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76627.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","code_information":[{"code":"241","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29764.6,"maximum":39347.42,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39347.42},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31560.17},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29764.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33225.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","code_information":[{"code":"240","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":61285.75,"maximum":81016.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":81016.91},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":64982.85},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61285.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68412.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","code_information":[{"code":"239","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":105816.55,"maximum":139884.56,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":139884.56},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":112199.99},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105816.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118120.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass Without Cardiac Catheterization Without Mcc","code_information":[{"code":"236","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":90059.2,"maximum":119054.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":119054.07},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":95492.07},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90059.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100531.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass Without Cardiac Catheterization With Mcc","code_information":[{"code":"235","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":126174.9,"maximum":166797.35,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":166797.35},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":133786.47},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":126174.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":140846.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","code_information":[{"code":"234","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":117448.05,"maximum":155260.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":155260.86},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":124533.17},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":117448.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131104.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":19244.7,"10th_percentile":19244.7,"90th_percentile":19244.7,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","code_information":[{"code":"233","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":164371.8,"maximum":217291.87,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":217291.87},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":174287.62},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":164371.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":183484.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Ptca Without Mcc","code_information":[{"code":"232","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":130345.9,"maximum":172311.22,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":172311.22},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":138209.09},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":130345.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":145502.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Ptca With Mcc","code_information":[{"code":"231","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":181242.85,"maximum":239594.62,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":239594.62},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":192176.43},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":181242.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":202317.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":37481.32,"10th_percentile":37481.32,"90th_percentile":37481.32,"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":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cardiothoracic Procedures Without Mcc","code_information":[{"code":"229","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":67714.25,"maximum":89515.09,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":89515.09},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":71799.15},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67714.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75588.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":106369.1,"maximum":140615.0,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":140615.0},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":112785.88},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106369.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118737.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","code_information":[{"code":"221","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":108364.3,"maximum":143252.56,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":143252.56},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":114901.44},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108364.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":120964.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","code_information":[{"code":"220","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":114655.2,"maximum":151568.84,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":151568.84},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":121571.84},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":114655.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":127987.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":165083.45,"maximum":218232.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":218232.64},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":175042.21},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":165083.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":184279.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":141368.95,"maximum":186883.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":186883.18},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":149897.11},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":141368.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":157807.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":141368.95,"maximum":186883.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":186883.18},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":149897.11},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":141368.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":157807.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":210330.2,"maximum":278046.74,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":278046.74},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":223018.49},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":210330.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":234787.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":214075.5,"maximum":282997.85,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":282997.85},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":226989.73},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":214075.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":238968.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":122698.35,"maximum":162201.51,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":162201.51},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":130100.2},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":122698.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":136965.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":233793.15,"maximum":309063.67,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":309063.67},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":247896.86},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":233793.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":260978.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complex Aortic Arch Procedures","code_information":[{"code":"209","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":243354.2,"maximum":321702.93,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":321702.93},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":258034.68},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":243354.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":271651.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory System Diagnosis With Ventilator Support <=96 Hours","code_information":[{"code":"208","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":59097.05,"maximum":78123.55,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":78123.55},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":62662.11},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59097.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65968.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":81736.56,"10th_percentile":81736.56,"90th_percentile":81736.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3715.3,"10th_percentile":3715.3,"90th_percentile":3715.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory System Diagnosis With Ventilator Support >96 Hours","code_information":[{"code":"207","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":138346.05,"maximum":182887.04,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":182887.04},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":146691.86},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":138346.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":154432.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System Diagnoses Without Mcc","code_information":[{"code":"206","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20233.65,"maximum":26747.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":26747.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21454.26},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20233.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22586.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":13664.48,"10th_percentile":13664.48,"90th_percentile":13664.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System Diagnoses With Mcc","code_information":[{"code":"205","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39366.5,"maximum":52040.68,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":52040.68},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41741.31},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39366.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43944.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":15164.48,"10th_percentile":15164.48,"90th_percentile":15164.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Signs And Symptoms","code_information":[{"code":"204","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17359.1,"maximum":22947.92,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22947.92},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18406.3},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17359.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19377.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":14405.0,"maximum":19042.74,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19042.74},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15273.99},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14405.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16080.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":20880.8,"maximum":27603.45,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27603.45},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22140.45},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20880.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23308.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3379.12,"10th_percentile":3379.12,"90th_percentile":3379.12,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":15374.65,"maximum":20324.57,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20324.57},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16302.13},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15374.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17162.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":11211.16,"10th_percentile":11211.16,"90th_percentile":11211.16,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":23634.95,"maximum":31244.3,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":31244.3},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25060.74},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23634.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26383.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":26935.36,"10th_percentile":26935.36,"90th_percentile":26935.36,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":37928.15,"maximum":50139.25,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":50139.25},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40216.19},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37928.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42338.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":15398.3,"maximum":20355.84,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20355.84},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16327.21},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15398.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17188.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":20405.65,"maximum":26975.32,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":26975.32},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21636.63},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20405.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22778.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":40574.8,"maximum":53638.0,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":53638.0},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43022.5},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40574.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45292.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":13512.75,"maximum":17863.23,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":17863.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14327.91},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13512.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15084.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":14894.71,"10th_percentile":14894.71,"90th_percentile":14894.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":7357.73,"10th_percentile":7357.73,"90th_percentile":7357.73,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":9002.09,"10th_percentile":9002.09,"90th_percentile":9002.09,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":17326.85,"maximum":22905.29,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22905.29},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18372.1},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17326.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19341.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3681.26,"10th_percentile":3681.26,"90th_percentile":3681.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":39843.26,"10th_percentile":39843.26,"90th_percentile":39843.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":12993.32,"10th_percentile":6706.66,"90th_percentile":15164.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":28259.6,"maximum":37357.88,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":37357.88},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29964.38},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28259.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31545.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":6852.4,"10th_percentile":6852.4,"90th_percentile":6852.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":36360.61,"10th_percentile":36360.61,"90th_percentile":36360.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":10323.36,"10th_percentile":7496.66,"90th_percentile":12803.36,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":13803.0,"maximum":18246.92,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":18246.92},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14635.67},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13803.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15408.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":15635.45,"10th_percentile":15635.45,"90th_percentile":15635.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":14479.49,"10th_percentile":14479.49,"90th_percentile":14479.49,"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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":14895.19,"10th_percentile":14895.19,"90th_percentile":14895.19,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":11244.99,"10th_percentile":11244.99,"90th_percentile":11244.99,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chronic Obstructive Pulmonary Disease With Cc","code_information":[{"code":"191","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18124.5,"maximum":23959.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23959.75},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19217.87},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18124.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20232.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3748.33,"10th_percentile":3748.33,"90th_percentile":3748.33,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":23815.55,"maximum":31483.05,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":31483.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25252.24},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23815.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26584.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":10278.59,"10th_percentile":6852.4,"90th_percentile":13704.8,"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 Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":21814.27,"10th_percentile":21814.27,"90th_percentile":21814.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":21624.68,"10th_percentile":21624.68,"90th_percentile":21624.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":7582.24,"10th_percentile":3413.33,"90th_percentile":15164.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":26561.1,"maximum":35112.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":35112.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28163.41},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26561.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29649.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":23199.86,"10th_percentile":23199.86,"90th_percentile":23199.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":7430.6,"10th_percentile":6484.33,"90th_percentile":17084.31,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":19361.53,"10th_percentile":19361.53,"90th_percentile":19361.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":13504.48,"10th_percentile":13504.48,"90th_percentile":13504.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"1 through 10","median_amount":33030.46,"10th_percentile":33030.46,"90th_percentile":33030.46,"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":"Pleural Effusion Without Cc/Mcc","code_information":[{"code":"188","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15419.8,"maximum":20384.26,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20384.26},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16350.01},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15419.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17212.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pleural Effusion With Cc","code_information":[{"code":"187","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21265.65,"maximum":28112.2,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28112.2},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22548.51},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21265.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23738.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3791.12,"10th_percentile":3791.12,"90th_percentile":3791.12,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pleural Effusion With Mcc","code_information":[{"code":"186","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33507.75,"maximum":44295.69,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":44295.69},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35529.12},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33507.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37404.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Trauma Without Cc/Mcc","code_information":[{"code":"185","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16909.75,"maximum":22353.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22353.9},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17929.84},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16909.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18876.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3681.86,"10th_percentile":3681.86,"90th_percentile":3681.86,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":22878.15,"maximum":30243.85,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30243.85},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24258.29},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22878.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25538.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":32892.85,"maximum":43482.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43482.82},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34877.13},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32892.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36717.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Neoplasms Without Cc/Mcc","code_information":[{"code":"182","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16206.7,"maximum":21424.5,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":21424.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17184.38},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16206.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18091.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Neoplasms With Cc","code_information":[{"code":"181","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23026.5,"maximum":30439.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30439.96},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24415.59},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23026.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25704.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3398.33,"10th_percentile":3398.33,"90th_percentile":3398.33,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Neoplasms With Mcc","code_information":[{"code":"180","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37969.0,"maximum":50193.25,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":50193.25},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40259.5},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37969.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42384.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Infections And Inflammations Without Cc/Mcc","code_information":[{"code":"179","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16232.5,"maximum":21458.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":21458.61},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17211.74},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16232.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18120.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3791.12,"10th_percentile":3791.12,"90th_percentile":3791.12,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":20984.0,"maximum":27739.87,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27739.87},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22249.87},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20984.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23424.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":17130.99,"10th_percentile":17130.99,"90th_percentile":17130.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":22075.58,"10th_percentile":22075.58,"90th_percentile":22075.58,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":33598.05,"maximum":44415.06,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":44415.06},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35624.87},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33598.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37504.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":11163.6,"10th_percentile":11163.6,"90th_percentile":11163.6,"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 Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":22291.79,"10th_percentile":22291.79,"90th_percentile":22291.79,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":24098.53,"10th_percentile":24098.53,"90th_percentile":24098.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":13018.32,"10th_percentile":13018.32,"90th_percentile":13018.32,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":17307.5,"maximum":22879.71,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22879.71},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18351.59},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17307.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19320.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":18605.99,"10th_percentile":18605.99,"90th_percentile":18605.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":29532.4,"maximum":39040.46,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39040.46},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31313.96},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29532.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32966.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":21186.18,"10th_percentile":21186.18,"90th_percentile":21186.18,"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":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Orbital Procedures Without Cc/Mcc","code_information":[{"code":"114","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29089.5,"maximum":38454.97,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":38454.97},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30844.34},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29089.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32472.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":33000.35,"maximum":43624.93,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43624.93},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34991.12},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33000.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36837.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intraocular Procedures With Cc/Mcc","code_information":[{"code":"116","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38874.15,"maximum":51389.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51389.82},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41219.26},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38874.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43394.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intraocular Procedures Without Cc/Mcc","code_information":[{"code":"117","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23325.35,"maximum":30835.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30835.03},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24732.47},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23325.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26037.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Major Eye Infections With Cc/Mcc","code_information":[{"code":"121","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25010.95,"maximum":33063.31,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":33063.31},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26519.75},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25010.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27919.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Major Eye Infections Without Cc/Mcc","code_information":[{"code":"122","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16894.7,"maximum":22334.01,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22334.01},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17913.88},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16894.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18859.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neurological Eye Disorders","code_information":[{"code":"123","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17169.9,"maximum":22697.81,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22697.81},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18205.68},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17169.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19166.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","code_information":[{"code":"124","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28446.65,"maximum":37605.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":37605.15},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30162.71},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28446.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31754.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of The Eye Without Mcc","code_information":[{"code":"125","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16507.7,"maximum":21822.41,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":21822.41},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17503.54},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16507.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18427.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sinus And Mastoid Procedures With Cc/Mcc","code_information":[{"code":"135","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":46655.0,"maximum":61675.74,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":61675.74},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49469.49},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46655.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52080.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sinus And Mastoid Procedures Without Cc/Mcc","code_information":[{"code":"136","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21828.95,"maximum":28856.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28856.86},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23145.79},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21828.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24367.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":32103.8,"maximum":42439.73,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42439.73},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34040.48},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32103.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35836.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":19053.3,"maximum":25187.58,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25187.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20202.7},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19053.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21268.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Salivary Gland Procedures","code_information":[{"code":"139","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26567.55,"maximum":35121.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":35121.07},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28170.25},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26567.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29656.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":16902.26,"10th_percentile":16902.26,"90th_percentile":16902.26,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head And Neck Procedures With Mcc","code_information":[{"code":"140","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":91703.95,"maximum":121228.36,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":121228.36},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":97236.04},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91703.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102367.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":46893.65,"maximum":61991.22,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":61991.22},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49722.54},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46893.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52346.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":34322.6,"maximum":45372.88,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":45372.88},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36393.13},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34322.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38313.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":80551.9,"maximum":106485.87,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":106485.87},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":85411.24},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80551.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89918.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","code_information":[{"code":"144","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37257.35,"maximum":49252.48,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":49252.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39504.92},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37257.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41589.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","code_information":[{"code":"145","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25849.45,"maximum":34171.77,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":34171.77},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27408.83},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25849.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28855.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ear, Nose, Mouth And Throat Malignancy With Mcc","code_information":[{"code":"146","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45524.1,"maximum":60180.74,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":60180.74},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48270.37},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45524.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50817.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":27337.25,"maximum":36138.57,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":36138.57},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28986.39},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27337.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30516.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":17137.65,"maximum":22655.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22655.18},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18171.49},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17137.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19130.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dysequilibrium","code_information":[{"code":"149","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16159.4,"maximum":21361.98,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":21361.98},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17134.23},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16159.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18038.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":20008.56,"10th_percentile":20008.56,"90th_percentile":20008.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Epistaxis With Mcc","code_information":[{"code":"150","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28627.25,"maximum":37843.89,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":37843.89},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30354.21},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28627.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31956.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Epistaxis Without Mcc","code_information":[{"code":"151","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15781.0,"maximum":20861.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20861.75},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16733.0},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15781.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17616.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Otitis Media And Uri With Mcc","code_information":[{"code":"152","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25417.3,"maximum":33600.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":33600.49},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26950.61},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25417.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28372.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Otitis Media And Uri Without Mcc","code_information":[{"code":"153","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15871.3,"maximum":20981.12,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20981.12},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16828.75},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15871.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17716.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","code_information":[{"code":"154","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33615.25,"maximum":44437.8,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":44437.8},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35643.11},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33615.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37524.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","code_information":[{"code":"155","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19704.75,"maximum":26048.76,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":26048.76},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20893.45},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19704.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21996.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","code_information":[{"code":"156","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14858.65,"maximum":19642.44,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19642.44},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15755.01},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14858.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16586.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dental And Oral Diseases With Mcc","code_information":[{"code":"157","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36911.2,"maximum":48794.89,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":48794.89},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39137.89},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36911.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41203.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dental And Oral Diseases With Cc","code_information":[{"code":"158","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19560.7,"maximum":25858.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25858.34},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20740.71},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19560.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21835.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dental And Oral Diseases Without Cc/Mcc","code_information":[{"code":"159","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15232.75,"maximum":20136.99,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20136.99},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16151.67},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15232.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17004.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Procedures With Mcc","code_information":[{"code":"163","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":96358.7,"maximum":127381.72,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":127381.72},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":102171.59},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96358.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107563.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Procedures With Cc","code_information":[{"code":"164","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":54266.0,"maximum":71737.13,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":71737.13},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":57539.63},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54266.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60576.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Procedures Without Cc/Mcc","code_information":[{"code":"165","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":41155.3,"maximum":54405.39,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":54405.39},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43638.02},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41155.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45940.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System O.R. Procedures With Mcc","code_information":[{"code":"166","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":80360.55,"maximum":106232.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":106232.91},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":85208.35},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80360.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89704.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System O.R. Procedures With Cc","code_information":[{"code":"167","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38773.1,"maximum":51256.23,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51256.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41112.11},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38773.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43281.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System O.R. Procedures Without Cc/Mcc","code_information":[{"code":"168","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29377.6,"maximum":38835.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":38835.82},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31149.82},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29377.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32793.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":63992.6,"maximum":84595.24,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":84595.24},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":67852.99},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63992.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71433.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":11696.0,"maximum":15461.57,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":15461.57},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12401.57},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11696.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13056.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":14715.45,"10th_percentile":14715.45,"90th_percentile":14715.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":17922.92,"10th_percentile":17922.92,"90th_percentile":20880.8,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":27268.45,"maximum":36047.62,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":36047.62},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28913.44},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27268.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30439.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":11020.09,"10th_percentile":11020.09,"90th_percentile":11020.09,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":16761.4,"maximum":22157.79,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22157.79},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17772.54},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16761.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18710.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":55762.1,"10th_percentile":55762.1,"90th_percentile":55762.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":21512.28,"10th_percentile":21512.28,"90th_percentile":21531.6,"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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":16137.69,"10th_percentile":16137.69,"90th_percentile":16137.69,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":28566.21,"10th_percentile":28566.21,"90th_percentile":28566.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":11244.99,"10th_percentile":11244.99,"90th_percentile":11244.99,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":34384.95,"maximum":45455.3,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":45455.3},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36459.24},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34384.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38383.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":20117.55,"maximum":26594.47,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":26594.47},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21331.15},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20117.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22456.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":13953.5,"maximum":18445.88,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":18445.88},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14795.25},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13953.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15576.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"1 through 10","median_amount":9112.88,"10th_percentile":9112.88,"90th_percentile":9112.88,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":51490.35,"maximum":68067.85,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":68067.85},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":54596.54},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51490.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57477.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":32542.4,"maximum":43019.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43019.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34505.54},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32542.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36326.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":23905.65,"10th_percentile":23905.65,"90th_percentile":23905.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":24611.05,"maximum":32534.66,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":32534.66},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26095.73},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24611.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27472.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":86440.75,"maximum":114270.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":114270.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":91655.34},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86440.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96492.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pancreas, Liver And Shunt Procedures With Mcc","code_information":[{"code":"405","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":117615.75,"maximum":155482.55,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":155482.55},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":124710.99},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":117615.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131292.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pancreas, Liver And Shunt Procedures With Cc","code_information":[{"code":"406","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":62354.3,"maximum":82429.48,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":82429.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":66115.86},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62354.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69604.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","code_information":[{"code":"407","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":47721.4,"maximum":63085.47,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":63085.47},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50600.22},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47721.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53270.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","code_information":[{"code":"408","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":76660.4,"maximum":101341.48,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":101341.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":81284.98},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76660.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85574.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","code_information":[{"code":"409","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":46811.95,"maximum":61883.22,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":61883.22},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49635.91},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46811.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52255.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","code_information":[{"code":"410","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34135.55,"maximum":45125.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":45125.61},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36194.8},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34135.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38104.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy With C.D.E. With Mcc","code_information":[{"code":"411","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":71020.95,"maximum":93886.39,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":93886.39},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":75305.33},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71020.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79279.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":45203.75,"maximum":59757.26,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":59757.26},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47930.69},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45203.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50460.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":35700.75,"maximum":47194.73,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":47194.73},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37854.42},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35700.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39852.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":76595.9,"maximum":101256.22,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":101256.22},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":81216.59},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76595.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85502.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":44434.05,"maximum":58739.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":58739.75},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47114.56},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44434.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49600.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":29310.95,"maximum":38747.71,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":38747.71},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31079.15},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29310.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32719.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":10211.59,"10th_percentile":10211.59,"90th_percentile":10211.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":51307.6,"maximum":67826.26,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":67826.26},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":54402.76},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51307.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57273.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":36369.4,"maximum":48078.66,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":48078.66},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38563.41},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36369.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40598.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"1 through 10","median_amount":57661.06,"10th_percentile":57661.06,"90th_percentile":57661.06,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":7358.32,"10th_percentile":7358.32,"90th_percentile":7358.32,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":22589.06,"10th_percentile":22589.06,"90th_percentile":22589.06,"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":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":29364.7,"maximum":38818.77,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":38818.77},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31136.14},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29364.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32779.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"1 through 10","median_amount":41525.48,"10th_percentile":41525.48,"90th_percentile":41525.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":26625.48,"10th_percentile":26625.48,"90th_percentile":26625.48,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":73252.65,"maximum":96836.6,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":96836.6},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":77671.66},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73252.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81770.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":37356.25,"maximum":49383.23,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":49383.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39609.79},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37356.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41700.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":143654.4,"maximum":189904.44,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":189904.44},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":152320.44},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143654.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":160358.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Spinal Fusion Except Cervical Without Mcc","code_information":[{"code":"448","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":91177.2,"maximum":120532.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":120532.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":96677.52},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91177.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101779.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","code_information":[{"code":"450","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":114586.4,"maximum":151477.89,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":151477.89},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":121498.89},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":114586.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":127910.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Single Level Spinal Fusion Except Cervical Without Mcc","code_information":[{"code":"451","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":69453.6,"maximum":91814.43,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":91814.43},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":73643.43},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69453.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77529.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","code_information":[{"code":"456","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":180673.1,"maximum":238841.43,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":238841.43},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":191572.31},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":180673.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":201681.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":128206.65,"maximum":169483.23,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":169483.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":135940.79},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":128206.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143114.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":89710.9,"maximum":118593.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":118593.64},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":95122.76},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89710.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100142.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","code_information":[{"code":"461","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":118744.5,"maximum":156974.71,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":156974.71},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":125907.83},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118744.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":132552.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","code_information":[{"code":"462","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":57190.0,"maximum":75602.52,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":75602.52},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":60640.02},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57190.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63840.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":73696.49,"10th_percentile":73696.49,"90th_percentile":73696.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":60939.39,"10th_percentile":60939.39,"90th_percentile":63218.39,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"1 through 10","median_amount":76002.96,"10th_percentile":76002.96,"90th_percentile":76002.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":69984.15,"10th_percentile":69984.15,"90th_percentile":69984.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","code_information":[{"code":"463","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":122539.25,"maximum":161991.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":161991.19},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":129931.5},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":122539.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":136788.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","code_information":[{"code":"464","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":66966.05,"maximum":88526.0,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":88526.0},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":71005.82},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66966.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74752.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","code_information":[{"code":"465","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39209.55,"maximum":51833.2,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51833.2},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41574.89},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39209.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43768.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":14910.7,"10th_percentile":14910.7,"90th_percentile":14910.7,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Revision Of Hip Or Knee Replacement With Mcc","code_information":[{"code":"466","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":111916.1,"maximum":147947.88,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":147947.88},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":118667.5},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":111916.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":124929.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Revision Of Hip Or Knee Replacement With Cc","code_information":[{"code":"467","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":75821.9,"maximum":100233.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":100233.03},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":80395.9},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75821.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84638.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":10278.59,"10th_percentile":10278.59,"90th_percentile":10278.59,"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 Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3748.33,"10th_percentile":3748.33,"90th_percentile":10804.57,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","code_information":[{"code":"468","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":59082.0,"maximum":78103.66,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":78103.66},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":62646.16},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59082.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65952.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3721.2,"10th_percentile":3721.2,"90th_percentile":3721.2,"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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":60662.1,"10th_percentile":60662.1,"90th_percentile":60662.1,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":295.0,"10th_percentile":295.0,"90th_percentile":295.0,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","code_information":[{"code":"469","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":65213.8,"maximum":86209.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":86209.61},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":69147.86},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65213.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72796.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":9369.99,"10th_percentile":9369.99,"90th_percentile":9369.99,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","code_information":[{"code":"470","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":41471.35,"maximum":54823.2,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":54823.2},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43973.13},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41471.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46293.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"1 through 10","median_amount":85100.32,"10th_percentile":85100.32,"90th_percentile":85100.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":53226.07,"10th_percentile":53226.07,"90th_percentile":53226.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":39618.13,"10th_percentile":39618.13,"90th_percentile":39618.13,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3791.12,"10th_percentile":3791.12,"90th_percentile":3791.12,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":36105.47,"10th_percentile":36105.47,"90th_percentile":36105.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":49552.0,"10th_percentile":36982.4,"90th_percentile":70795.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3791.12,"10th_percentile":3791.12,"90th_percentile":3791.12,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cervical Spinal Fusion With Mcc","code_information":[{"code":"471","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":103817.05,"maximum":137241.31,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":137241.31},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":110079.87},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":103817.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115888.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cervical Spinal Fusion With Cc","code_information":[{"code":"472","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":63341.15,"maximum":83734.05,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":83734.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":67162.24},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63341.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70706.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cervical Spinal Fusion Without Cc/Mcc","code_information":[{"code":"473","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":52487.95,"maximum":69386.63,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":69386.63},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55654.32},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52487.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58591.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","code_information":[{"code":"476","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25374.3,"maximum":33543.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":33543.64},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26905.02},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25374.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28324.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","code_information":[{"code":"477","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":74273.9,"maximum":98186.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":98186.64},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":78754.52},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74273.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82910.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","code_information":[{"code":"478","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":52872.8,"maximum":69895.38,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":69895.38},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":56062.38},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52872.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59020.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","code_information":[{"code":"479","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39966.35,"maximum":52833.66,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":52833.66},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42377.34},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39966.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44613.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip And Femur Procedures Except Major Joint With Mcc","code_information":[{"code":"480","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":62614.45,"maximum":82773.39,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":82773.39},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":66391.7},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62614.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69895.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip And Femur Procedures Except Major Joint With Cc","code_information":[{"code":"481","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45031.75,"maximum":59529.88,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":59529.88},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47748.32},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45031.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50268.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":10647.69,"10th_percentile":10647.69,"90th_percentile":10647.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":14993.32,"10th_percentile":14993.32,"90th_percentile":14993.32,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","code_information":[{"code":"482","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35066.5,"maximum":46356.28,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":46356.28},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37181.91},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35066.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39144.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":43775.12,"10th_percentile":43775.12,"90th_percentile":43775.12,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"1 through 10","median_amount":53615.66,"10th_percentile":53615.66,"90th_percentile":53615.66,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":6807.73,"10th_percentile":6807.73,"90th_percentile":6807.73,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":59595.85,"maximum":78782.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":78782.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":63191.0},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59595.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66525.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":69382.65,"maximum":91720.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":91720.64},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":73568.2},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69382.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77450.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":44958.65,"maximum":59433.24,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":59433.24},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47670.81},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44958.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50186.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":33673.3,"maximum":44514.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":44514.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35704.66},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33673.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37588.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","code_information":[{"code":"488","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38031.35,"maximum":50275.68,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":50275.68},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40325.61},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38031.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42453.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","code_information":[{"code":"489","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24011.2,"maximum":31741.69,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":31741.69},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25459.69},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24011.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26803.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","code_information":[{"code":"492","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":78939.4,"maximum":104354.22,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":104354.22},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":83701.47},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78939.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88118.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":51711.78,"10th_percentile":51711.78,"90th_percentile":51711.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","code_information":[{"code":"493","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":54526.15,"maximum":72081.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":72081.03},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":57815.47},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54526.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60866.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":43139.75,"maximum":57028.74,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":57028.74},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45742.18},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43139.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48156.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":12993.32,"10th_percentile":12993.32,"90th_percentile":12993.32,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","code_information":[{"code":"495","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":77952.55,"maximum":103049.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":103049.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":82655.08},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77952.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87016.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Soft Tissue Procedures With Mcc","code_information":[{"code":"500","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":68043.2,"maximum":89949.95,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":89949.95},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":72147.95},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68043.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75955.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Soft Tissue Procedures With Cc","code_information":[{"code":"501","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37584.15,"maximum":49684.5,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":49684.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39851.44},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37584.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41954.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Soft Tissue Procedures Without Cc/Mcc","code_information":[{"code":"502","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28936.85,"maximum":38253.17,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":38253.17},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30682.48},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28936.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32301.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Foot Procedures With Mcc","code_information":[{"code":"503","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":60008.65,"maximum":79328.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":79328.64},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":63628.71},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60008.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66986.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Foot Procedures With Cc","code_information":[{"code":"504","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":40187.8,"maximum":53126.4,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":53126.4},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42612.15},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40187.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44860.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Foot Procedures Without Cc/Mcc","code_information":[{"code":"505","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38545.2,"maximum":50954.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":50954.96},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40870.46},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38545.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43027.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Thumb Or Joint Procedures","code_information":[{"code":"506","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29007.8,"maximum":38346.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":38346.96},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30757.71},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29007.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32380.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","code_information":[{"code":"507","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38837.6,"maximum":51341.5,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51341.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41180.5},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38837.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43353.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","code_information":[{"code":"508","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32559.6,"maximum":43042.28,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43042.28},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34523.78},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32559.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36345.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","code_information":[{"code":"510","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":64940.75,"maximum":85848.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":85848.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":68858.34},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64940.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72492.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":44707.1,"maximum":59100.71,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":59100.71},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47404.08},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44707.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49905.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":35591.1,"maximum":47049.78,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":47049.78},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37738.15},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35591.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39729.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":33847.45,"maximum":44744.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":44744.75},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35889.32},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33847.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37783.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":21979.45,"maximum":29055.81,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29055.81},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23305.37},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21979.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24535.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":68518.35,"maximum":90578.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":90578.07},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":72651.76},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68518.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76485.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":44679.15,"maximum":59063.76,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":59063.76},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47374.45},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44679.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49874.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":33039.05,"maximum":43676.09,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43676.09},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35032.15},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33039.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36880.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":80351.95,"maximum":106221.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":106221.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":85199.23},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80351.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89695.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":43004.3,"maximum":56849.68,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":56849.68},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45598.56},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43004.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48004.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":32118.85,"maximum":42459.63,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42459.63},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34056.44},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32118.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35853.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":61709.3,"maximum":81576.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":81576.82},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":65431.95},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61709.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68884.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":25768.84,"10th_percentile":25768.84,"90th_percentile":25768.84,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":45530.55,"maximum":60189.27,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":60189.27},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48277.21},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45530.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50824.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"1 through 10","median_amount":65670.74,"10th_percentile":65670.74,"90th_percentile":65670.74,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":14693.46,"10th_percentile":14693.46,"90th_percentile":14693.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":67031.44,"10th_percentile":67031.44,"90th_percentile":67031.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fractures Of Femur With Mcc","code_information":[{"code":"533","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33705.55,"maximum":44557.17,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":44557.17},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35738.86},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33705.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37624.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fractures Of Femur Without Mcc","code_information":[{"code":"534","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17331.15,"maximum":22910.97,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22910.97},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18376.66},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17331.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19346.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":6666.66,"10th_percentile":6666.66,"90th_percentile":6666.66,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fractures Of Hip And Pelvis With Mcc","code_information":[{"code":"535","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27563.0,"maximum":36437.0,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":36437.0},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29225.75},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27563.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30768.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fractures Of Hip And Pelvis Without Mcc","code_information":[{"code":"536","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17363.4,"maximum":22953.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22953.61},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18410.86},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17363.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19382.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":7346.73,"10th_percentile":7346.73,"90th_percentile":7346.73,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","code_information":[{"code":"537","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20517.45,"maximum":27123.11,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27123.11},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21755.18},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20517.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22903.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","code_information":[{"code":"538","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15486.45,"maximum":20472.37,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20472.37},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16420.68},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15486.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17287.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":42348.55,"maximum":55982.81,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":55982.81},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44903.25},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42348.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47272.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":33060.27,"10th_percentile":33060.27,"90th_percentile":33060.27,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":27870.45,"maximum":36843.44,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":36843.44},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29551.75},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27870.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31111.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":21211.69,"10th_percentile":21211.69,"90th_percentile":22236.93,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":16929.1,"maximum":22379.48,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22379.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17950.36},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16929.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18897.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":37979.75,"maximum":50207.46,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":50207.46},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40270.9},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37979.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42396.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":22102.0,"maximum":29217.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29217.82},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23435.32},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22102.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24672.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","code_information":[{"code":"544","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16223.9,"maximum":21447.24,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":21447.24},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17202.62},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16223.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18110.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Connective Tissue Disorders With Mcc","code_information":[{"code":"545","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":53356.55,"maximum":70534.88,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":70534.88},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":56575.31},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53356.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59560.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Connective Tissue Disorders With Cc","code_information":[{"code":"546","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24798.1,"maximum":32781.93,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":32781.93},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26294.06},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24798.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27681.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Connective Tissue Disorders Without Cc/Mcc","code_information":[{"code":"547","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17978.3,"maximum":23766.48,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23766.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19062.85},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17978.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20068.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septic Arthritis With Mcc","code_information":[{"code":"548","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":41514.35,"maximum":54880.04,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":54880.04},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44018.73},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41514.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46341.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septic Arthritis With Cc","code_information":[{"code":"549","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25954.8,"maximum":34311.04,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":34311.04},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27520.54},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25954.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28972.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septic Arthritis Without Cc/Mcc","code_information":[{"code":"550","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18793.15,"maximum":24843.67,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24843.67},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19926.86},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18793.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20978.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Medical Back Problems With Mcc","code_information":[{"code":"551","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36036.15,"maximum":47638.11,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":47638.11},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38210.05},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36036.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40226.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Medical Back Problems Without Mcc","code_information":[{"code":"552","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20667.95,"maximum":27322.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27322.07},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21914.76},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20667.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23071.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":11163.59,"10th_percentile":11163.59,"90th_percentile":11163.59,"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 Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3347.35,"10th_percentile":3347.35,"90th_percentile":3347.35,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":27870.45,"maximum":36843.44,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":36843.44},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29551.75},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27870.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31111.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":17847.15,"maximum":23593.1,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23593.1},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18923.79},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17847.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19922.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","code_information":[{"code":"555","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28418.7,"maximum":37568.2,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":37568.2},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30133.07},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28418.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31723.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":17857.9,"maximum":23607.31,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23607.31},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18935.19},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17857.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19934.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":31968.35,"maximum":42260.67,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42260.67},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33896.86},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31968.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35685.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":7582.24,"10th_percentile":7582.24,"90th_percentile":7582.24,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":19203.8,"maximum":25386.53,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25386.53},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20362.28},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19203.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21436.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":11162.39,"10th_percentile":11162.39,"90th_percentile":11162.39,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":19892.54,"10th_percentile":19892.54,"90th_percentile":19892.54,"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":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":14301.21,"10th_percentile":14301.21,"90th_percentile":14301.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":40095.35,"maximum":53004.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":53004.19},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42514.13},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40095.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44757.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue With Cc","code_information":[{"code":"560","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24211.15,"maximum":32006.01,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":32006.01},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25671.7},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24211.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27026.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":11643.83,"10th_percentile":7570.6,"90th_percentile":15136.27,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","code_information":[{"code":"561","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17283.85,"maximum":22848.45,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22848.45},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18326.51},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17283.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19293.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","code_information":[{"code":"562","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30633.2,"maximum":40495.67,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":40495.67},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32481.17},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30633.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34195.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":19253.25,"maximum":25451.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25451.9},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20414.71},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19253.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21492.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":11244.99,"10th_percentile":11244.99,"90th_percentile":11244.99,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":33187.4,"maximum":43872.2,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43872.2},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35189.45},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33187.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37046.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9001.59,"10th_percentile":9001.59,"90th_percentile":9001.59,"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":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","code_information":[{"code":"565","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20949.6,"maximum":27694.4,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27694.4},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22213.4},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20949.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23385.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","code_information":[{"code":"566","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16109.95,"maximum":21296.6,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":21296.6},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17081.79},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16109.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17983.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Debridement With Mcc","code_information":[{"code":"570","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":63233.65,"maximum":83591.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":83591.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":67048.26},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63233.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70586.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Debridement With Cc","code_information":[{"code":"571","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36324.25,"maximum":48018.97,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":48018.97},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38515.53},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36324.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40548.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":24645.45,"maximum":32580.14,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":32580.14},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26132.2},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24645.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27511.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","code_information":[{"code":"573","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":140855.1,"maximum":186203.89,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":186203.89},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":149352.27},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":140855.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":157233.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft For Skin Ulcer Or Cellulitis With Cc","code_information":[{"code":"574","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":74635.1,"maximum":98664.13,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":98664.13},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":79137.51},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74635.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83313.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","code_information":[{"code":"575","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38635.5,"maximum":51074.33,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51074.33},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40966.21},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38635.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43128.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","code_information":[{"code":"576","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":105375.8,"maximum":139301.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":139301.91},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":111732.66},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105375.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117628.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","code_information":[{"code":"577","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":56990.05,"maximum":75338.2,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":75338.2},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":60428.01},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56990.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63616.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","code_information":[{"code":"578","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34537.6,"maximum":45657.1,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":45657.1},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36621.1},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34537.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38553.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","code_information":[{"code":"579","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":69627.75,"maximum":92044.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":92044.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":73828.08},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69627.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77724.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mastectomy For Malignancy With Cc/Mcc","code_information":[{"code":"582","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":41421.9,"maximum":54757.83,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":54757.83},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43920.7},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41421.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46238.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":37074.6,"maximum":49010.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":49010.9},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39311.15},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37074.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41385.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":46025.05,"maximum":60842.98,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":60842.98},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48801.54},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46025.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51376.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":41475.65,"maximum":54828.88,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":54828.88},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43977.69},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41475.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46298.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":41608.95,"maximum":55005.1,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":55005.1},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44119.03},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41608.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46447.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":25505.45,"maximum":33717.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":33717.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27044.08},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25505.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28471.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":18636.2,"maximum":24636.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24636.19},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19760.44},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18636.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20803.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Skin Disorders With Mcc","code_information":[{"code":"595","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45595.05,"maximum":60274.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":60274.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48345.6},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45595.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50896.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Skin Disorders Without Mcc","code_information":[{"code":"596","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23273.75,"maximum":30766.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30766.82},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24677.75},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23273.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25980.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignant Breast Disorders With Mcc","code_information":[{"code":"597","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35842.65,"maximum":47382.32,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":47382.32},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38004.88},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35842.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40010.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignant Breast Disorders With Cc","code_information":[{"code":"598","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24322.95,"maximum":32153.81,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":32153.81},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25790.25},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24322.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27151.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":16542.1,"maximum":21867.89,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":21867.89},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17540.01},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16542.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18465.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":22394.4,"maximum":29604.36,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29604.36},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23745.36},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22394.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24998.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":13007.5,"maximum":17195.31,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":17195.31},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13792.19},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13007.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14520.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":30557.95,"maximum":40396.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":40396.19},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32401.38},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30557.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34111.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":22325.31,"10th_percentile":22325.31,"90th_percentile":22325.31,"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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":18724.35,"maximum":24752.72,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24752.72},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19853.91},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18724.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20901.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":10278.59,"10th_percentile":10278.59,"90th_percentile":10278.59,"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 Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":23755.26,"10th_percentile":23755.26,"90th_percentile":23755.26,"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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":13680.46,"10th_percentile":13680.46,"90th_percentile":14701.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":21731.56,"10th_percentile":21731.56,"90th_percentile":21731.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":15164.48,"10th_percentile":15164.48,"90th_percentile":15164.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":31650.15,"maximum":41840.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":41840.03},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33559.46},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31650.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35330.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":19694.0,"maximum":26034.55,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":26034.55},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20882.05},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19694.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21984.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":32533.8,"maximum":43008.17,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43008.17},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34496.42},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32533.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36316.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":19487.6,"maximum":25761.7,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25761.7},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20663.2},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19487.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21753.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":47123.7,"maximum":62295.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":62295.34},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":49966.46},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47123.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52603.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":30084.95,"maximum":39770.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39770.9},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31899.84},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30084.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33583.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":74979.1,"maximum":99118.88,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":99118.88},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":79502.26},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74979.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83697.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","code_information":[{"code":"768","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23039.4,"maximum":30457.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30457.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24429.27},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23039.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25718.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":24789.14,"10th_percentile":24789.14,"90th_percentile":24789.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postpartum And Post Abortion Diagnoses With O.R. Procedures","code_information":[{"code":"769","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36330.7,"maximum":48027.5,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":48027.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38522.37},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36330.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40555.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Abortion With D&C, Aspiration Curettage Or Hysterotomy","code_information":[{"code":"770","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21558.05,"maximum":28498.74,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28498.74},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22858.55},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21558.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24064.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","code_information":[{"code":"776","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14076.05,"maximum":18607.88,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":18607.88},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14925.2},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14076.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15712.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":15233.98,"10th_percentile":15233.98,"90th_percentile":15233.98,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Abortion Without D&C","code_information":[{"code":"779","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18087.95,"maximum":23911.43,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23911.43},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19179.12},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18087.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20191.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section With Sterilization With Mcc","code_information":[{"code":"783","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":52784.65,"maximum":69778.85,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":69778.85},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55968.91},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52784.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58922.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":22792.15,"maximum":30130.16,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30130.16},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24167.1},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22792.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25442.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section With Sterilization Without Cc/Mcc","code_information":[{"code":"785","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20592.7,"maximum":27222.59,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27222.59},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21834.97},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20592.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22987.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":23061.0,"10th_percentile":23061.0,"90th_percentile":23061.0,"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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":20522.0,"10th_percentile":20522.0,"90th_percentile":20522.0,"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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section Without Sterilization With Mcc","code_information":[{"code":"786","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35464.25,"maximum":46882.09,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":46882.09},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37603.65},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35464.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39588.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":25942.0,"10th_percentile":25942.0,"90th_percentile":25942.0,"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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section Without Sterilization With Cc","code_information":[{"code":"787","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24011.2,"maximum":31741.69,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":31741.69},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":25459.69},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24011.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26803.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":21950.0,"10th_percentile":21950.0,"90th_percentile":21950.0,"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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":30964.62,"10th_percentile":30964.62,"90th_percentile":30964.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":40211.45,"maximum":53157.67,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":53157.67},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42637.23},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40211.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44887.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":30493.45,"maximum":40310.92,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":40310.92},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32332.99},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30493.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34039.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":39933.31,"10th_percentile":39933.31,"90th_percentile":39933.31,"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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures For Obesity With Mcc","code_information":[{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":62079.1,"maximum":82065.68,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":82065.68},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":65824.06},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62079.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69297.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures For Obesity With Cc","code_information":[{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34406.45,"maximum":45483.73,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":45483.73},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36482.04},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34406.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38407.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Procedures For Obesity Without Cc/Mcc","code_information":[{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32430.6,"maximum":42871.74,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42871.74},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34386.99},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32430.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36201.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","code_information":[{"code":"623","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38568.85,"maximum":50986.23,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":50986.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40895.54},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38568.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43053.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","code_information":[{"code":"624","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26915.85,"maximum":35581.5,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":35581.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28539.56},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26915.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30045.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","code_information":[{"code":"626","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32237.1,"maximum":42615.95,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42615.95},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34181.82},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32237.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35985.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","code_information":[{"code":"627","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28558.45,"maximum":37752.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":37752.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30281.26},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28558.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31879.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","code_information":[{"code":"628","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":80126.2,"maximum":105923.11,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":105923.11},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":84959.86},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80126.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89443.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","code_information":[{"code":"630","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31379.25,"maximum":41481.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":41481.91},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33272.22},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31379.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35028.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Diabetes With Mcc","code_information":[{"code":"637","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30889.05,"maximum":40833.89,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":40833.89},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32752.45},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30889.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34480.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":19268.3,"maximum":25471.8,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25471.8},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20430.67},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19268.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21508.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":31706.85,"10th_percentile":31706.85,"90th_percentile":31706.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3676.31,"10th_percentile":3676.31,"90th_percentile":3676.31,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":13355.8,"maximum":17655.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":17655.75},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14161.5},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13355.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14908.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3376.12,"10th_percentile":3376.12,"90th_percentile":3376.12,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":28715.4,"maximum":37960.42,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":37960.42},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30447.67},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28715.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32054.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":3955.98,"10th_percentile":3955.98,"90th_percentile":3955.98,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3677.44,"10th_percentile":3677.44,"90th_percentile":3677.44,"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":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":16731.3,"maximum":22118.0,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22118.0},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17740.63},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16731.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18676.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":16819.06,"10th_percentile":16819.06,"90th_percentile":16819.06,"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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":16221.99,"10th_percentile":16221.99,"90th_percentile":16418.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":6891.6,"10th_percentile":6891.6,"90th_percentile":6891.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":15164.48,"10th_percentile":15164.48,"90th_percentile":15164.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":30575.15,"maximum":40418.93,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":40418.93},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32419.61},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30575.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34130.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":35391.15,"maximum":46785.45,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":46785.45},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37526.14},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35391.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39506.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endocrine Disorders With Cc","code_information":[{"code":"644","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22037.5,"maximum":29132.55,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29132.55},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23366.93},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22037.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24600.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":10211.59,"10th_percentile":10211.59,"90th_percentile":10211.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endocrine Disorders Without Cc/Mcc","code_information":[{"code":"645","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16518.45,"maximum":21836.62,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":21836.62},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17514.94},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16518.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18439.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney Transplant With Hemodialysis With Mcc","code_information":[{"code":"650","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":101080.1,"maximum":133623.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":133623.19},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":107177.82},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":101080.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112833.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney Transplant With Hemodialysis Without Mcc","code_information":[{"code":"651","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":79674.7,"maximum":105326.25,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":105326.25},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":84481.12},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79674.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88939.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney Transplant","code_information":[{"code":"652","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":69434.25,"maximum":91788.85,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":91788.85},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":73622.91},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69434.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77508.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Bladder Procedures With Mcc","code_information":[{"code":"653","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":111722.6,"maximum":147692.08,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":147692.08},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":118462.33},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":111722.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":124713.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Bladder Procedures With Cc","code_information":[{"code":"654","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":60184.95,"maximum":79561.7,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":79561.7},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":63815.64},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60184.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67183.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Bladder Procedures Without Cc/Mcc","code_information":[{"code":"655","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45506.9,"maximum":60158.01,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":60158.01},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48252.13},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45506.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50798.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Neoplasm With Mcc","code_information":[{"code":"656","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":68451.7,"maximum":90489.96,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":90489.96},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":72581.09},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68451.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76411.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Neoplasm With Cc","code_information":[{"code":"657","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39345.0,"maximum":52012.26,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":52012.26},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41718.51},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39345.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43920.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","code_information":[{"code":"658","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33363.7,"maximum":44105.26,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":44105.26},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35376.38},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33363.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37243.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","code_information":[{"code":"659","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":54629.35,"maximum":72217.46,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":72217.46},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":57924.9},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54629.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60981.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Non-Neoplasm With Cc","code_information":[{"code":"660","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28416.55,"maximum":37565.36,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":37565.36},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30130.79},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28416.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31720.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","code_information":[{"code":"661","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22261.1,"maximum":29428.14,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29428.14},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23604.01},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22261.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24849.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Bladder Procedures With Mcc","code_information":[{"code":"662","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":65822.25,"maximum":87013.95,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":87013.95},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":69793.02},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65822.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73476.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Bladder Procedures With Cc","code_information":[{"code":"663","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32684.3,"maximum":43207.12,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43207.12},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34656.0},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32684.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36484.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Bladder Procedures Without Cc/Mcc","code_information":[{"code":"664","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22508.35,"maximum":29754.99,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29754.99},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23866.18},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22508.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25125.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Procedures With Mcc","code_information":[{"code":"668","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":62780.0,"maximum":82992.24,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":82992.24},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":66567.24},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62780.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70080.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Procedures With Cc","code_information":[{"code":"669","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33368.0,"maximum":44110.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":44110.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35380.94},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33368.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37248.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Procedures Without Cc/Mcc","code_information":[{"code":"670","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21011.95,"maximum":27776.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27776.82},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22279.51},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21011.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23455.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urethral Procedures With Cc/Mcc","code_information":[{"code":"671","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38592.5,"maximum":51017.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51017.49},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":40920.62},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38592.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43080.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urethral Procedures Without Cc/Mcc","code_information":[{"code":"672","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23209.25,"maximum":30681.55,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30681.55},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24609.36},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23209.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25908.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":90334.4,"maximum":119417.88,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":119417.88},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":95783.88},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90334.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100838.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":50279.9,"maximum":66467.69,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":66467.69},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53313.06},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50279.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56126.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":35290.1,"maximum":46651.87,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":46651.87},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37419.0},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35290.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39393.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":31841.5,"maximum":42092.98,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42092.98},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33762.36},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31841.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35544.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":25713.54,"10th_percentile":25713.54,"90th_percentile":25713.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":18829.7,"maximum":24891.99,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24891.99},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19965.61},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18829.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21019.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":7430.6,"10th_percentile":7430.6,"90th_percentile":7430.6,"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 Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":44135.52,"10th_percentile":44135.52,"90th_percentile":44135.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":3791.12,"10th_percentile":3791.12,"90th_percentile":14993.32,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":12906.45,"maximum":17061.73,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":17061.73},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13685.04},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12906.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14407.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":7582.24,"10th_percentile":7582.24,"90th_percentile":7582.24,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":38779.55,"maximum":51264.76,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51264.76},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41118.95},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38779.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43288.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":22527.7,"maximum":29780.57,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29780.57},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23886.7},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22527.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25147.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":16991.45,"maximum":22461.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22461.91},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18016.47},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16991.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18967.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":24946.45,"maximum":32978.05,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":32978.05},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26451.36},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24946.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27847.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Infections Without Mcc","code_information":[{"code":"690","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17404.25,"maximum":23007.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":23007.61},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18454.17},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17404.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19428.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":14341.74,"10th_percentile":14341.74,"90th_percentile":14341.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":34592.34,"10th_percentile":34592.34,"90th_percentile":34592.34,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":22746.72,"10th_percentile":22746.72,"90th_percentile":22746.72,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":9317.26,"10th_percentile":1044.52,"90th_percentile":11373.36,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":28906.75,"maximum":38213.38,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":38213.38},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30650.57},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28906.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32268.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":16806.55,"maximum":22217.48,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22217.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17820.41},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16806.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18760.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":24591.7,"maximum":32509.08,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":32509.08},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26075.21},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24591.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27451.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":14813.5,"maximum":19582.76,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19582.76},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15707.13},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14813.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16536.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":23172.7,"maximum":30633.23,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30633.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24570.61},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23172.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25867.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":35569.6,"maximum":47021.36,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":47021.36},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37715.36},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35569.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39705.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":13760.18,"10th_percentile":13760.18,"90th_percentile":13760.18,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":21822.5,"maximum":28848.33,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28848.33},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23138.96},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21822.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24360.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":14832.85,"maximum":19608.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19608.34},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15727.65},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14832.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16557.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":43006.45,"maximum":56852.53,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":56852.53},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45600.84},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43006.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48007.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":32985.3,"maximum":43605.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43605.03},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34975.16},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32985.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36820.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Penis Procedures With Cc/Mcc","code_information":[{"code":"709","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":50032.65,"maximum":66140.84,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":66140.84},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53050.9},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50032.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55850.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Penis Procedures Without Cc/Mcc","code_information":[{"code":"710","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30125.8,"maximum":39824.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39824.91},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31943.16},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30125.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33628.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Prostatectomy With Cc/Mcc","code_information":[{"code":"713","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32323.1,"maximum":42729.63,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42729.63},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34273.01},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32323.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36081.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Prostatectomy Without Cc/Mcc","code_information":[{"code":"714","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22734.1,"maximum":30053.42,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30053.42},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24105.55},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22734.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25377.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System O.R. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","code_information":[{"code":"718","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28876.65,"maximum":38173.59,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":38173.59},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30618.65},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28876.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32234.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare 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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Male Reproductive System With Mcc","code_information":[{"code":"722","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38908.55,"maximum":51435.29,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51435.29},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41255.73},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38908.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43432.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Male Reproductive System With Cc","code_information":[{"code":"723","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24568.05,"maximum":32477.82,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":32477.82},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26050.13},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24568.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27424.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Male Reproductive System Without Cc/Mcc","code_information":[{"code":"724","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14097.55,"maximum":18636.31,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":18636.31},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14947.99},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14097.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15736.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Benign Prostatic Hypertrophy With Mcc","code_information":[{"code":"725","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25159.3,"maximum":33259.42,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":33259.42},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26677.05},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25159.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28084.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System Diagnoses With Cc/Mcc","code_information":[{"code":"729","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22762.05,"maximum":30090.37,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30090.37},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24135.18},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22762.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25408.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare 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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System Diagnoses Without Cc/Mcc","code_information":[{"code":"730","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14448.0,"maximum":19099.58,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19099.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15319.58},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14448.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16128.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare 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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","code_information":[{"code":"734","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45795.0,"maximum":60538.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":60538.86},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48557.61},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45795.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51120.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":28928.25,"maximum":38241.8,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":38241.8},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30673.36},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28928.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32292.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":76851.75,"maximum":101594.44,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":101594.44},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":81487.88},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76851.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85788.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":44302.9,"maximum":58566.37,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":58566.37},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":46975.5},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44302.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49454.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":31572.75,"maximum":41737.71,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":41737.71},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33477.39},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31572.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35244.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":77030.2,"maximum":101830.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":101830.34},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":81677.09},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77030.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85987.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":38906.4,"maximum":51432.45,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51432.45},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41253.45},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38906.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43430.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":30661.15,"maximum":40532.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":40532.61},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32510.8},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30661.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34226.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":39448.2,"maximum":52148.69,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":52148.69},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41827.94},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39448.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44035.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":26675.05,"maximum":35263.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":35263.18},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28284.24},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26675.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29776.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":44055.65,"maximum":58239.52,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":58239.52},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":46713.33},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44055.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49178.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":37347.65,"maximum":49371.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":49371.86},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39600.67},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37347.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41690.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","code_information":[{"code":"747","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18483.55,"maximum":24434.39,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24434.39},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19598.58},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18483.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20632.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":29826.95,"maximum":39429.84,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39429.84},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31626.28},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29826.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33295.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":55203.4,"maximum":72976.33,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":72976.33},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":58533.58},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55203.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61622.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","code_information":[{"code":"750","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31729.7,"maximum":41945.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":41945.19},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33643.81},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31729.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35419.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Female Reproductive System With Mcc","code_information":[{"code":"754","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39596.55,"maximum":52344.8,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":52344.8},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41985.23},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39596.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44200.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Female Reproductive System With Cc","code_information":[{"code":"755","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23387.7,"maximum":30917.45,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30917.45},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24798.58},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23387.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26107.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Female Reproductive System Without Cc/Mcc","code_information":[{"code":"756","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20650.75,"maximum":27299.33,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27299.33},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21896.52},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20650.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23052.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infections, Female Reproductive System With Mcc","code_information":[{"code":"757","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30785.85,"maximum":40697.46,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":40697.46},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32643.02},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30785.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34365.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infections, Female Reproductive System With Cc","code_information":[{"code":"758","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21048.5,"maximum":27825.14,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27825.14},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22318.26},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21048.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23496.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infections, Female Reproductive System Without Cc/Mcc","code_information":[{"code":"759","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14267.4,"maximum":18860.84,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":18860.84},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15128.09},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14267.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15926.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","code_information":[{"code":"833","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11242.35,"maximum":14861.86,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":14861.86},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":11920.55},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11242.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12549.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":10365.89,"10th_percentile":10365.89,"90th_percentile":10365.89,"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":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Leukemia With Mcc","code_information":[{"code":"834","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":118032.85,"maximum":156033.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":156033.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":125153.25},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118032.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131757.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Leukemia With Cc","code_information":[{"code":"835","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":44844.7,"maximum":59282.61,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":59282.61},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47549.98},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44844.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50059.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Leukemia Without Cc/Mcc","code_information":[{"code":"836","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26219.25,"maximum":34660.63,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":34660.63},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27800.94},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26219.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29268.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","code_information":[{"code":"839","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31043.85,"maximum":41038.53,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":41038.53},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32916.59},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31043.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34653.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Mcc","code_information":[{"code":"840","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":69550.35,"maximum":91942.33,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":91942.33},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":73746.02},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69550.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77637.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Cc","code_information":[{"code":"841","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35075.1,"maximum":46367.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":46367.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37191.03},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35075.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39153.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","code_information":[{"code":"842","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21723.6,"maximum":28717.59,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28717.59},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23034.09},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21723.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24249.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","code_information":[{"code":"843","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":42888.2,"maximum":56696.21,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":56696.21},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45475.46},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42888.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47875.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","code_information":[{"code":"844","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26174.1,"maximum":34600.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":34600.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27753.07},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26174.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29217.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":7430.6,"10th_percentile":7430.6,"90th_percentile":7430.6,"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 Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","code_information":[{"code":"847","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28126.3,"maximum":37181.66,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":37181.66},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29823.04},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28126.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31396.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","code_information":[{"code":"848","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18262.1,"maximum":24141.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24141.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19363.77},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18262.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20385.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","code_information":[{"code":"853","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":106179.9,"maximum":140364.89,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":140364.89},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":112585.26},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106179.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118526.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","code_information":[{"code":"854","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":42959.15,"maximum":56790.0,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":56790.0},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45550.69},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42959.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47954.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","code_information":[{"code":"855","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32189.8,"maximum":42553.42,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42553.42},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34131.67},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32189.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35932.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","code_information":[{"code":"856","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":97797.05,"maximum":129283.15,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":129283.15},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":103696.71},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97797.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":109168.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","code_information":[{"code":"857","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":46042.25,"maximum":60865.71,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":60865.71},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48819.78},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46042.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51396.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","code_information":[{"code":"858","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29947.35,"maximum":39589.0,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39589.0},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31753.94},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29947.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33429.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative And Post-Traumatic Infections With Mcc","code_information":[{"code":"862","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39209.55,"maximum":51833.2,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51833.2},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41574.89},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39209.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43768.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative And Post-Traumatic Infections Without Mcc","code_information":[{"code":"863","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21454.85,"maximum":28362.31,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28362.31},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22749.13},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21454.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23949.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fever And Inflammatory Conditions","code_information":[{"code":"864","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19085.55,"maximum":25230.21,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25230.21},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20236.9},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19085.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21304.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":32213.45,"maximum":42584.68,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42584.68},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34156.75},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32213.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35959.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Viral Illness Without Mcc","code_information":[{"code":"866","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18696.4,"maximum":24715.77,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24715.77},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19824.27},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18696.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20870.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":7496.66,"10th_percentile":7496.66,"90th_percentile":7496.66,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Infectious And Parasitic Diseases Diagnoses With Mcc","code_information":[{"code":"867","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45003.8,"maximum":59492.93,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":59492.93},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47718.68},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45003.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50236.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Infectious And Parasitic Diseases Diagnoses With Cc","code_information":[{"code":"868","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22168.65,"maximum":29305.92,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29305.92},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23505.99},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22168.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24746.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":15688.55,"maximum":20739.53,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":20739.53},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":16634.97},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15688.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17512.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":148603.7,"maximum":196447.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":196447.18},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":157568.3},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":148603.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":165883.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":41763.75,"maximum":55209.74,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":55209.74},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44283.17},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41763.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46620.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":7430.6,"10th_percentile":7430.6,"90th_percentile":7430.6,"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 Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":41671.36,"10th_percentile":41671.36,"90th_percentile":41671.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":13168.32,"10th_percentile":13168.32,"90th_percentile":13168.32,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":22000.95,"maximum":29084.23,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29084.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23328.17},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22000.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24559.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":13794.79,"10th_percentile":13794.79,"90th_percentile":13794.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":8610.38,"10th_percentile":8610.38,"90th_percentile":8610.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":14993.32,"10th_percentile":14993.32,"90th_percentile":14993.32,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":83095.35,"maximum":109848.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":109848.19},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":88108.13},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":83095.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92757.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":20644.3,"maximum":27290.8,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27290.8},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21889.68},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20644.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23044.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":20229.35,"maximum":26742.26,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":26742.26},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21449.7},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20229.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22581.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":23086.7,"maximum":30519.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30519.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24479.42},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23086.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25771.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":42275.45,"maximum":55886.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":55886.18},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":44825.74},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42275.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47191.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Organic Disturbances And Intellectual Disability","code_information":[{"code":"884","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34591.35,"maximum":45728.16,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":45728.16},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":36678.09},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34591.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38613.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":30031.2,"maximum":39699.85,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39699.85},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":31842.85},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30031.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33523.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":44618.95,"maximum":58984.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":58984.18},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":47310.61},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44618.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49807.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":23024.35,"maximum":30437.12,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30437.12},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24413.31},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23024.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25701.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence, Left Ama","code_information":[{"code":"894","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13263.35,"maximum":17533.53,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":17533.53},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14063.47},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13263.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14805.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","code_information":[{"code":"895","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30435.4,"maximum":40234.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":40234.18},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32271.43},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30435.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33974.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","code_information":[{"code":"896","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37519.65,"maximum":49599.23,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":49599.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39783.04},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37519.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41882.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","code_information":[{"code":"897","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18980.2,"maximum":25090.94,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25090.94},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20125.19},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18980.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21187.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":7464.12,"10th_percentile":7464.12,"90th_percentile":7464.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":7620.75,"10th_percentile":7620.75,"90th_percentile":7620.75,"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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":9166.97,"10th_percentile":9166.97,"90th_percentile":9166.97,"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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":18913.06,"10th_percentile":18913.06,"90th_percentile":18913.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":7582.24,"10th_percentile":7582.24,"90th_percentile":7582.24,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":6151.34,"10th_percentile":6151.34,"90th_percentile":6151.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":15164.48,"10th_percentile":15164.48,"90th_percentile":15164.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridements For Injuries With Mcc","code_information":[{"code":"901","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":90226.9,"maximum":119275.77,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":119275.77},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":95669.89},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90226.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100718.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridements For Injuries With Cc","code_information":[{"code":"902","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":41161.75,"maximum":54413.92,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":54413.92},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43644.86},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41161.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45948.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridements For Injuries Without Cc/Mcc","code_information":[{"code":"903","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25146.4,"maximum":33242.37,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":33242.37},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26663.37},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25146.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28070.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","code_information":[{"code":"760","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21661.25,"maximum":28635.17,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28635.17},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22967.98},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21661.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24180.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","code_information":[{"code":"761","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12265.75,"maximum":16214.75,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":16214.75},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":13005.69},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12265.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13692.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section Without Sterilization Without Cc/Mcc","code_information":[{"code":"788","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20614.2,"maximum":27251.01,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27251.01},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21857.76},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20614.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23011.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":23061.0,"10th_percentile":23061.0,"90th_percentile":23061.0,"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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":20522.0,"10th_percentile":20522.0,"90th_percentile":20522.0,"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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"1 through 10","median_amount":45278.01,"10th_percentile":45278.01,"90th_percentile":45278.01,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":26671.71,"10th_percentile":18521.73,"90th_percentile":41019.54,"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":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neonates, Died Or Transferred To Another Acute Care Facility","code_information":[{"code":"789","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38747.3,"maximum":51222.13,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":51222.13},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41084.75},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38747.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43252.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":2030.29,"10th_percentile":2030.29,"90th_percentile":2030.29,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":127785.25,"maximum":168926.16,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":168926.16},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":135493.97},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":127785.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142644.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":87268.5,"maximum":115364.9,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":115364.9},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":92533.02},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87268.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97416.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":52657.8,"maximum":69611.16,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":69611.16},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":55834.41},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52657.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58780.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":6453.0,"10th_percentile":6453.0,"90th_percentile":6453.0,"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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":89646.4,"maximum":118508.37,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":118508.37},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":95054.37},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89646.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100070.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":3752.19,"10th_percentile":3752.19,"90th_percentile":3752.19,"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":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":31731.85,"maximum":41948.03,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":41948.03},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33646.09},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31731.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35421.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":6141.0,"10th_percentile":6141.0,"90th_percentile":6141.0,"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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":1760.0,"10th_percentile":1760.0,"90th_percentile":3520.0,"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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":4674.67,"10th_percentile":3835.35,"90th_percentile":4735.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":4295.7,"maximum":5678.72,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":5678.72},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":4554.84},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4295.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4795.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":2151.0,"10th_percentile":2047.0,"90th_percentile":4302.0,"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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":1760.0,"10th_percentile":1760.0,"90th_percentile":2816.0,"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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"1 through 10","median_amount":5195.36,"10th_percentile":5195.36,"90th_percentile":5195.36,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"1 through 10","median_amount":3433.46,"10th_percentile":3433.46,"90th_percentile":3433.46,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":1421.59,"10th_percentile":1421.59,"90th_percentile":1421.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":4263.39,"10th_percentile":3523.08,"90th_percentile":6009.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With Sterilization And/Or D&C With Mcc","code_information":[{"code":"796","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25090.5,"maximum":33168.47,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":33168.47},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26604.1},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25090.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28008.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare 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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With Sterilization And/Or D&C With Cc","code_information":[{"code":"797","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21508.6,"maximum":28433.37,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28433.37},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22806.12},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21508.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24009.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","code_information":[{"code":"798","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20577.65,"maximum":27202.7,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":27202.7},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21819.01},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20577.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22970.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Splenic Procedures With Mcc","code_information":[{"code":"799","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":97371.35,"maximum":128720.4,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":128720.4},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":103245.33},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97371.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108693.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Splenic Procedures With Cc","code_information":[{"code":"800","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":60402.1,"maximum":79848.77,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":79848.77},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":64045.89},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60402.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67425.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Splenic Procedures Without Cc/Mcc","code_information":[{"code":"801","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":41041.35,"maximum":54254.76,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":54254.76},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":43517.19},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41041.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45813.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","code_information":[{"code":"802","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":85658.15,"maximum":113236.09,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":113236.09},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":90825.53},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85658.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95618.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","code_information":[{"code":"803","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39966.35,"maximum":52833.66,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":52833.66},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":42377.34},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39966.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44613.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","code_information":[{"code":"804","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29154.0,"maximum":38540.23,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":38540.23},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30912.73},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29154.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32544.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery Without Sterilization Or D&C With Mcc","code_information":[{"code":"805","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23202.8,"maximum":30673.02,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":30673.02},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":24602.52},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23202.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25900.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery Without Sterilization Or D&C With Cc","code_information":[{"code":"806","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16211.0,"maximum":21430.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":21430.19},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":17188.94},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16211.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18096.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":14983.0,"10th_percentile":14983.0,"90th_percentile":14983.0,"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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":17736.86,"10th_percentile":17736.86,"90th_percentile":17736.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":14495.3,"maximum":19162.11,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":19162.11},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15369.74},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14495.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16180.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":16989.0,"10th_percentile":14924.44,"90th_percentile":17849.0,"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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"1 through 10","median_amount":13540.0,"10th_percentile":13484.7,"90th_percentile":14983.0,"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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"1 through 10","median_amount":22433.37,"10th_percentile":22433.37,"90th_percentile":22992.98,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"1 through 10","median_amount":14915.31,"10th_percentile":14915.31,"90th_percentile":14915.31,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":7483.0,"10th_percentile":7483.0,"90th_percentile":7483.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"1 through 10","median_amount":16730.48,"10th_percentile":8887.88,"90th_percentile":19551.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","code_information":[{"code":"808","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":47469.85,"maximum":62752.93,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":62752.93},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50333.5},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47469.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52989.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","code_information":[{"code":"809","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27216.85,"maximum":35979.41,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":35979.41},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28858.72},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27216.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30381.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":22501.9,"maximum":29746.47,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":29746.47},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23859.34},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22501.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25118.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":30192.45,"maximum":39913.01,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":39913.01},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":32013.83},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30192.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33703.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":19741.3,"maximum":26097.08,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":26097.08},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20932.21},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19741.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22036.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":10868.59,"10th_percentile":10868.59,"90th_percentile":10868.59,"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 Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":1013.09,"10th_percentile":1013.09,"90th_percentile":1013.09,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coagulation Disorders","code_information":[{"code":"813","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32793.95,"maximum":43352.08,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43352.08},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34772.26},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32793.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36607.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":11373.36,"10th_percentile":11373.36,"90th_percentile":11373.36,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Reticuloendothelial And Immunity Disorders With Mcc","code_information":[{"code":"814","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45724.05,"maximum":60445.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":60445.07},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":48482.38},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45724.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51040.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":21801.0,"maximum":28819.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28819.91},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23116.16},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21801.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24336.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses With O.R. Procedures With Mcc","code_information":[{"code":"817","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":49054.4,"maximum":64847.64,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":64847.64},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":52013.64},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49054.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54758.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses With O.R. Procedures With Cc","code_information":[{"code":"818","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24922.8,"maximum":32946.78,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":32946.78},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26426.28},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24922.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27820.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Leukemia With Major O.R. Procedures With Cc","code_information":[{"code":"821","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":48129.9,"maximum":63625.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":63625.49},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":51033.36},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48129.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53726.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Leukemia With Major O.R. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","code_information":[{"code":"823","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":98573.2,"maximum":130309.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":130309.19},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":104519.69},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98573.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":110035.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","code_information":[{"code":"824","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":48710.4,"maximum":64392.88,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":64392.88},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":51648.88},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48710.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54374.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","code_information":[{"code":"825","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29012.1,"maximum":38352.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":38352.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":30762.27},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29012.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32385.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare 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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","code_information":[{"code":"826","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":100572.7,"maximum":132952.43,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":132952.43},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":106639.81},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100572.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112267.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","code_information":[{"code":"827","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":49690.8,"maximum":65688.93,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":65688.93},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":52688.43},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49690.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55468.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","code_information":[{"code":"828","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36631.7,"maximum":48425.4,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":48425.4},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38841.53},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36631.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40891.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","code_information":[{"code":"829","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":67940.0,"maximum":89813.52,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":89813.52},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":72038.52},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67940.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75840.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","code_information":[{"code":"830","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32357.5,"maximum":42775.11,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42775.11},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34309.49},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32357.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36120.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Procedures With Mcc","code_information":[{"code":"831","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25853.75,"maximum":34177.46,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":34177.46},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27413.39},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25853.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28860.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts For Injuries With Cc/Mcc","code_information":[{"code":"904","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":78971.65,"maximum":104396.85,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":104396.85},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":83735.66},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78971.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88154.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts For Injuries Without Cc/Mcc","code_information":[{"code":"905","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31893.1,"maximum":42161.19,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":42161.19},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":33817.07},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31893.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35601.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":42896.8,"maximum":56707.57,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":56707.57},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":45484.57},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42896.8},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47884.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":28223.05,"maximum":37309.56,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":37309.56},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29925.62},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28223.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31504.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":35143.9,"maximum":46458.6,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":46458.6},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":37263.98},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35143.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39230.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":19038.25,"maximum":25167.68,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25167.68},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20186.74},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19038.25},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21252.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":36154.4,"maximum":47794.44,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":47794.44},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":38335.44},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36154.4},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40358.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Allergic Reactions Without Mcc","code_information":[{"code":"916","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14325.45,"maximum":18937.58,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":18937.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":15189.64},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14325.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15991.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":33720.6,"maximum":44577.06,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":44577.06},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35754.81},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33720.6},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37641.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Poisoning And Toxic Effects Of Drugs Without Mcc","code_information":[{"code":"918","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18427.65,"maximum":24360.5,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":24360.5},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":19539.31},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18427.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20570.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":39362.2,"maximum":52035.0,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":52035.0},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":41736.75},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39362.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43939.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":21549.45,"maximum":28487.37,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28487.37},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":22849.43},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21549.45},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24055.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":21880.55,"maximum":28925.07,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":28925.07},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":23200.51},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21880.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24424.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare 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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":459035.75,"maximum":606823.91,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":606823.91},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":486727.35},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":459035.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":512412.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":154213.05,"maximum":203862.48,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":203862.48},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":163516.04},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":154213.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":172144.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":69247.2,"maximum":91541.58,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":91541.58},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":73424.58},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69247.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77299.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":83725.3,"maximum":110680.95,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":110680.95},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":88776.08},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":83725.3},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93460.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":47527.9,"maximum":62829.67,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":62829.67},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":50395.05},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47527.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53054.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":50243.35,"maximum":66419.37,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":66419.37},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":53274.31},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50243.35},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56085.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":43595.55,"maximum":57631.29,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":57631.29},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":46225.48},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43595.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48664.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rehabilitation With Cc/Mcc","code_information":[{"code":"945","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33294.9,"maximum":44014.31,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":44014.31},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":35303.43},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33294.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37166.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rehabilitation Without Cc/Mcc","code_information":[{"code":"946","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24656.2,"maximum":32594.35,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":32594.35},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":26143.6},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24656.2},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27523.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":27292.1,"maximum":36078.89,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":36078.89},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":28938.51},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27292.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30465.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":17210.75,"maximum":22751.81,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":22751.81},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":18249.0},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17210.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19212.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":11373.36,"10th_percentile":11373.36,"90th_percentile":11373.36,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":25578.55,"maximum":33813.65,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":33813.65},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":27121.59},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25578.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28552.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":13495.55,"maximum":17840.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":17840.49},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":14309.68},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13495.55},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15064.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":11954.0,"maximum":15802.63,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":15802.63},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":12675.13},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11954.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13344.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":5778.1,"10th_percentile":5778.1,"90th_percentile":5778.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":144718.65,"maximum":191311.32,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":191311.32},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":153448.89},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":144718.65},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":161546.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":80904.5,"maximum":106951.99,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":106951.99},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":85785.11},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80904.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90312.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"1 through 10","median_amount":14693.45,"10th_percentile":14693.45,"90th_percentile":14693.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":163827.85,"maximum":216572.8,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":216572.8},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":173710.86},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":163827.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":182877.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Multiple Significant Trauma With Cc","code_information":[{"code":"958","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":90598.85,"maximum":119767.47,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":119767.47},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":96064.28},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90598.85},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101133.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","code_information":[{"code":"959","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":63298.15,"maximum":83677.21,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":83677.21},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":67116.65},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63298.15},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70658.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Multiple Significant Trauma With Mcc","code_information":[{"code":"963","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":58776.7,"maximum":77700.06,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":77700.06},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":62322.44},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58776.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65611.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":32950.9,"maximum":43559.56,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":43559.56},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":34938.68},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32950.9},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36782.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":20220.75,"maximum":26730.89,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":26730.89},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":21440.58},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20220.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22572.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Extensive O.R. Procedures With Mcc","code_information":[{"code":"969","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":131607.95,"maximum":173979.59,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":173979.59},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":139547.28},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":131607.95},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":146911.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Extensive O.R. Procedures Without Mcc","code_information":[{"code":"970","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":56704.1,"maximum":74960.18,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":74960.18},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":60124.81},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56704.1},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63297.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Major Related Condition With Mcc","code_information":[{"code":"974","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":62049.0,"maximum":82025.89,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":82025.89},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":65792.14},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62049.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69264.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":27842.5,"maximum":36806.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":36806.49},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":29522.12},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27842.5},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31080.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":19408.05,"maximum":25656.54,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":25656.54},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":20578.85},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19408.05},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21664.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","code_information":[{"code":"981","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":100873.7,"maximum":133350.34,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":133350.34},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":106958.96},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100873.7},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112603.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","code_information":[{"code":"982","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":52857.75,"maximum":69875.49,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":69875.49},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":56046.42},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52857.75},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59004.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","code_information":[{"code":"983","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36851.0,"maximum":48715.31,"payers_information":[{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"fee schedule","standard_charge_dollar":48715.31},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"fee schedule","standard_charge_dollar":39074.06},{"payer_name":"Centivo Medical Services","plan_name":"Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36851.0},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41136.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Extensive O.R. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertensive Encephalopathy With Mcc","code_information":[{"code":"077","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertensive Encephalopathy With Cc","code_information":[{"code":"078","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertensive Encephalopathy Without Cc/Mcc","code_information":[{"code":"079","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","code_information":[{"code":"222","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","code_information":[{"code":"223","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","code_information":[{"code":"224","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","code_information":[{"code":"226","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","code_information":[{"code":"227","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","code_information":[{"code":"246","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","code_information":[{"code":"247","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","code_information":[{"code":"248","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","code_information":[{"code":"249","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Deep Vein Thrombophlebitis With Cc/Mcc","code_information":[{"code":"294","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Deep Vein Thrombophlebitis Without Cc/Mcc","code_information":[{"code":"295","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendectomy With Complicated Principal Diagnosis With Mcc","code_information":[{"code":"338","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendectomy With Complicated Principal Diagnosis With Cc","code_information":[{"code":"339","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","code_information":[{"code":"340","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendectomy Without Complicated Principal Diagnosis With Mcc","code_information":[{"code":"341","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendectomy Without Complicated Principal Diagnosis With Cc","code_information":[{"code":"342","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","code_information":[{"code":"343","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Spinal Fusion With Mcc","code_information":[{"code":"453","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Spinal Fusion With Cc","code_information":[{"code":"454","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","code_information":[{"code":"455","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical With Mcc","code_information":[{"code":"459","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical Without Mcc","code_information":[{"code":"460","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Arthroscopy","code_information":[{"code":"509","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","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":"[All IP services (%BC): 88] [All Other IP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","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":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 23753 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 18384 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 2216] [Lower Level Neonate-Per Diem: 6710] [Higher Level Neonate-Per Diem: 12079] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 2.01 | Excess % of Charge: 70] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 21138 Days: 4 Additional Days: 2967] [Normal vag. Del. 4 day stay-Case Rate: 15432 Days: 4 Additional Days: 2967] [Normal Newborn-Per Diem: 1813] [Lower Level Neonate-Per Diem: 5369] [Higher Level Neonate-Per Diem: 10736] [Alcohol/ Chemical Dependency (%BC): 50] [Psych (%BC): 50] [Rehab (%BC): 50] [ECT (%BC): 50] [All Other IP (%BC): 50]","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":"[All IP services (%BC): 90] [All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 76] [All Other IP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 65] [MSDRG Base Rate: FEE SCHEDULE] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3763.31] [Surgical-Per Diem: 3763.31]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All IP services (%BC): 75.53] [All Other IP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inj cefazolin (wg crit care)","code_information":[{"code":"0753","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":3821.69,"10th_percentile":3821.69,"90th_percentile":3821.69,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inj, methylpred acetate 1 mg","code_information":[{"code":"0790","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":1525.01,"10th_percentile":1525.01,"90th_percentile":1525.01,"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":3078.14,"10th_percentile":2851.01,"90th_percentile":5861.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":3059.0,"10th_percentile":3059.0,"90th_percentile":3059.0,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1093.03,"10th_percentile":1093.03,"90th_percentile":1093.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":1089.73,"10th_percentile":726.49,"90th_percentile":1098.63,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":2472.85,"10th_percentile":2439.35,"90th_percentile":4644.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":1392.13,"10th_percentile":857.39,"90th_percentile":1579.41,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":117.58,"10th_percentile":117.58,"90th_percentile":142.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"16","median_amount":357.11,"10th_percentile":40.42,"90th_percentile":4384.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":133.93,"10th_percentile":73.44,"90th_percentile":784.8,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":107.28,"10th_percentile":107.28,"90th_percentile":108.48,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":624.78,"10th_percentile":624.78,"90th_percentile":679.85,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":106.56,"10th_percentile":104.43,"90th_percentile":345.41,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"20","median_amount":238.94,"10th_percentile":138.49,"90th_percentile":1053.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":568.09,"10th_percentile":568.09,"90th_percentile":568.09,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":121.17,"10th_percentile":121.17,"90th_percentile":314.83,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"77","median_amount":98.49,"10th_percentile":85.9,"90th_percentile":886.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"34","median_amount":156.45,"10th_percentile":40.3,"90th_percentile":957.5,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Type A ED Visits","code_information":[{"code":"5021","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":344.61,"10th_percentile":344.61,"90th_percentile":344.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":382.0,"10th_percentile":382.0,"90th_percentile":382.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":382.0,"10th_percentile":382.0,"90th_percentile":382.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":114.6,"10th_percentile":114.6,"90th_percentile":114.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":326.78,"10th_percentile":326.78,"90th_percentile":326.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":322.22,"10th_percentile":167.32,"90th_percentile":324.77,"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":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":322.22,"10th_percentile":322.22,"90th_percentile":322.22,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":306.23,"10th_percentile":306.23,"90th_percentile":306.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":114.6,"10th_percentile":114.6,"90th_percentile":114.6,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"22","median_amount":784.65,"10th_percentile":752.4,"90th_percentile":1470.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"21","median_amount":269.93,"10th_percentile":186.66,"90th_percentile":496.2,"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"136","median_amount":756.0,"10th_percentile":354.2,"90th_percentile":756.0,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"77","median_amount":626.76,"10th_percentile":252.11,"90th_percentile":719.99,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"22","median_amount":769.5,"10th_percentile":519.5,"90th_percentile":1472.6,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"1 through 10","median_amount":1324.9,"10th_percentile":1324.9,"90th_percentile":1324.9,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":610.81,"10th_percentile":610.81,"90th_percentile":731.33,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"16","median_amount":286.38,"10th_percentile":114.17,"90th_percentile":454.76,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"28","median_amount":291.95,"10th_percentile":219.21,"90th_percentile":432.32,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":273.6,"10th_percentile":273.6,"90th_percentile":273.6,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"166","median_amount":291.95,"10th_percentile":208.62,"90th_percentile":433.22,"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":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":123.01,"10th_percentile":123.01,"90th_percentile":123.01,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":324.77,"10th_percentile":178.58,"90th_percentile":501.5,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":687.12,"10th_percentile":626.15,"90th_percentile":1391.53,"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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":482.06,"10th_percentile":158.43,"90th_percentile":863.78,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"84","median_amount":668.61,"10th_percentile":314.47,"90th_percentile":970.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"31","median_amount":291.95,"10th_percentile":210.84,"90th_percentile":433.22,"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":"[All Other OP (%BC): 28]","count":"33","median_amount":273.6,"10th_percentile":146.5,"90th_percentile":1063.19,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Type A ED Visits","code_information":[{"code":"5023","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"38","median_amount":1460.37,"10th_percentile":1040.0,"90th_percentile":4667.08,"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":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"45","median_amount":581.71,"10th_percentile":279.84,"90th_percentile":1715.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"237","median_amount":1574.04,"10th_percentile":877.79,"90th_percentile":2314.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"186","median_amount":1487.52,"10th_percentile":773.9,"90th_percentile":1987.0,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"42","median_amount":1529.65,"10th_percentile":1028.88,"90th_percentile":3327.38,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"1 through 10","median_amount":1773.85,"10th_percentile":1773.85,"90th_percentile":1853.53,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"18","median_amount":1170.77,"10th_percentile":798.26,"90th_percentile":2923.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"67","median_amount":572.07,"10th_percentile":292.68,"90th_percentile":2163.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"59","median_amount":434.86,"10th_percentile":264.78,"90th_percentile":1028.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":396.86,"10th_percentile":396.86,"90th_percentile":396.86,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"290","median_amount":407.87,"10th_percentile":269.57,"90th_percentile":703.58,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":207.86,"10th_percentile":207.86,"90th_percentile":207.86,"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":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"18","median_amount":357.28,"10th_percentile":244.35,"90th_percentile":739.82,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":1115.53,"10th_percentile":1115.53,"90th_percentile":1115.53,"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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":287.16,"10th_percentile":287.16,"90th_percentile":287.16,"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":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"23","median_amount":843.53,"10th_percentile":432.32,"90th_percentile":1288.19,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"198","median_amount":1258.09,"10th_percentile":586.03,"90th_percentile":2894.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"53","median_amount":382.41,"10th_percentile":261.5,"90th_percentile":863.15,"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":"[All Other OP (%BC): 28]","count":"116","median_amount":630.52,"10th_percentile":345.18,"90th_percentile":2322.08,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"1 through 10","median_amount":2825.5,"10th_percentile":2825.5,"90th_percentile":2825.5,"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 Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Type A ED Visits","code_information":[{"code":"5024","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"41","median_amount":6177.41,"10th_percentile":1973.76,"90th_percentile":10485.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"111","median_amount":2638.98,"10th_percentile":802.03,"90th_percentile":5474.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"257","median_amount":4258.0,"10th_percentile":2021.33,"90th_percentile":4608.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. 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Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"248","median_amount":3195.06,"10th_percentile":1734.69,"90th_percentile":3819.02,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"67","median_amount":3753.53,"10th_percentile":1596.24,"90th_percentile":10951.36,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"1 through 10","median_amount":3364.53,"10th_percentile":3364.53,"90th_percentile":6442.22,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"18","median_amount":4151.47,"10th_percentile":2068.01,"90th_percentile":9926.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"144","median_amount":2463.27,"10th_percentile":656.72,"90th_percentile":4160.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"46","median_amount":933.54,"10th_percentile":425.41,"90th_percentile":2070.75,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":3022.51,"10th_percentile":3022.51,"90th_percentile":3022.51,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"236","median_amount":786.15,"10th_percentile":331.51,"90th_percentile":1539.18,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":381.81,"10th_percentile":179.26,"90th_percentile":541.5,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":781.63,"10th_percentile":367.71,"90th_percentile":1879.9,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":4371.22,"10th_percentile":3269.92,"90th_percentile":39983.22,"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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"20","median_amount":2396.5,"10th_percentile":835.98,"90th_percentile":7551.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"1 through 10","median_amount":2493.22,"10th_percentile":2493.22,"90th_percentile":2493.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"254","median_amount":4050.26,"10th_percentile":1269.11,"90th_percentile":10552.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"50","median_amount":898.84,"10th_percentile":355.57,"90th_percentile":2720.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"248","median_amount":2356.1,"10th_percentile":837.6,"90th_percentile":4722.1,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"1 through 10","median_amount":2698.63,"10th_percentile":2698.63,"90th_percentile":2811.59,"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":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"1 through 10","median_amount":582.0,"10th_percentile":582.0,"90th_percentile":582.0,"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 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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"19","median_amount":9474.92,"10th_percentile":2641.58,"90th_percentile":18224.06,"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":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"113","median_amount":3417.05,"10th_percentile":1267.93,"90th_percentile":6813.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"127","median_amount":4385.98,"10th_percentile":2307.42,"90th_percentile":4608.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. 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Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"103","median_amount":3634.99,"10th_percentile":819.0,"90th_percentile":4608.0,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"18","median_amount":3606.43,"10th_percentile":2771.88,"90th_percentile":20774.19,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"1 through 10","median_amount":5311.82,"10th_percentile":5311.82,"90th_percentile":5311.82,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":3159.31,"10th_percentile":3128.88,"90th_percentile":4035.69,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"130","median_amount":2985.69,"10th_percentile":888.04,"90th_percentile":7205.93,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":1362.45,"10th_percentile":583.32,"90th_percentile":1966.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":3628.06,"10th_percentile":2009.47,"90th_percentile":11293.89,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"100","median_amount":901.46,"10th_percentile":431.05,"90th_percentile":2356.11,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":158.03,"10th_percentile":158.03,"90th_percentile":428.35,"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":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1619.34,"10th_percentile":1338.73,"90th_percentile":1659.27,"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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":6717.62,"10th_percentile":6717.62,"90th_percentile":6717.62,"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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"16","median_amount":4194.48,"10th_percentile":2147.41,"90th_percentile":12536.9,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"137","median_amount":3663.8,"10th_percentile":1592.48,"90th_percentile":15204.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"31","median_amount":1187.83,"10th_percentile":471.42,"90th_percentile":2439.02,"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":"[All Other OP (%BC): 28]","count":"253","median_amount":2420.95,"10th_percentile":1169.32,"90th_percentile":7655.1,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"1 through 10","median_amount":5806.63,"10th_percentile":5806.63,"90th_percentile":5806.63,"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."}]}]},{"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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":10618.0,"10th_percentile":10618.0,"90th_percentile":10618.0,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":21589.98,"10th_percentile":21589.98,"90th_percentile":21589.98,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":3175.82,"10th_percentile":3175.82,"90th_percentile":3175.82,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":6263.95,"10th_percentile":6263.95,"90th_percentile":6263.95,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":6202.1,"10th_percentile":6202.1,"90th_percentile":6202.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":4365.37,"10th_percentile":3958.97,"90th_percentile":7335.29,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Skin Procedures","code_information":[{"code":"5051","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":304.47,"10th_percentile":184.47,"90th_percentile":1701.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"23","median_amount":907.15,"10th_percentile":321.05,"90th_percentile":3852.6,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"16","median_amount":756.0,"10th_percentile":456.32,"90th_percentile":2247.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":1605.52,"10th_percentile":1605.52,"90th_percentile":1605.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":101.59,"10th_percentile":95.49,"90th_percentile":626.38,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":248.81,"10th_percentile":248.81,"90th_percentile":1856.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":359.58,"10th_percentile":267.84,"90th_percentile":3212.4,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":245.28,"10th_percentile":245.28,"90th_percentile":367.99,"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":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":302.68,"10th_percentile":302.68,"90th_percentile":302.68,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":653.3,"10th_percentile":653.3,"90th_percentile":916.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":617.74,"10th_percentile":302.12,"90th_percentile":1757.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":172.6,"10th_percentile":102.74,"90th_percentile":228.18,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":1416.45,"10th_percentile":1416.45,"90th_percentile":1416.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":740.3,"10th_percentile":740.3,"90th_percentile":740.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":756.0,"10th_percentile":755.99,"90th_percentile":8318.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":1787.38,"10th_percentile":426.39,"90th_percentile":6224.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":1007.44,"10th_percentile":1007.44,"90th_percentile":1007.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1585.06,"10th_percentile":1585.06,"90th_percentile":1585.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2013.07,"10th_percentile":2013.07,"90th_percentile":2013.07,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":398.73,"10th_percentile":398.73,"90th_percentile":398.73,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":658.95,"10th_percentile":658.95,"90th_percentile":658.95,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"11","median_amount":1344.7,"10th_percentile":363.0,"90th_percentile":2467.07,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":575.82,"10th_percentile":575.82,"90th_percentile":1230.59,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":2665.69,"10th_percentile":2665.69,"90th_percentile":7606.98,"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 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":2145.67,"10th_percentile":2145.67,"90th_percentile":2145.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":1987.0,"10th_percentile":1987.0,"90th_percentile":1987.0,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":5332.35,"10th_percentile":5332.35,"90th_percentile":5332.35,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":13414.51,"10th_percentile":13414.51,"90th_percentile":13414.51,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":1284.92,"10th_percentile":1284.92,"90th_percentile":1284.92,"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":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Skin Procedures","code_information":[{"code":"5054","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":5694.99,"10th_percentile":1335.61,"90th_percentile":5695.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":2614.43,"10th_percentile":2614.43,"90th_percentile":2614.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3961.13,"10th_percentile":3961.13,"90th_percentile":3961.13,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":1259.57,"10th_percentile":1259.57,"90th_percentile":1259.57,"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":4612.0,"10th_percentile":4612.0,"90th_percentile":4612.0,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":2110.63,"10th_percentile":2110.63,"90th_percentile":2323.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":3604.04,"10th_percentile":3604.04,"90th_percentile":3604.04,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":1119.73,"10th_percentile":1119.73,"90th_percentile":1465.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.15,"10th_percentile":1152.15,"90th_percentile":1152.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":1426.45,"10th_percentile":1426.45,"90th_percentile":1812.55,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":1478.98,"10th_percentile":1478.98,"90th_percentile":1478.98,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":5275.89,"10th_percentile":4082.57,"90th_percentile":8542.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":4710.45,"10th_percentile":4710.45,"90th_percentile":4710.45,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":9070.37,"10th_percentile":9070.37,"90th_percentile":9070.37,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":9823.47,"10th_percentile":9823.47,"90th_percentile":9823.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":1888.24,"10th_percentile":1888.24,"90th_percentile":2006.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2236.72,"10th_percentile":2236.72,"90th_percentile":2236.72,"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":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":7082.04,"10th_percentile":7082.04,"90th_percentile":7082.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":5102.2,"10th_percentile":4629.71,"90th_percentile":14213.09,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":2471.61,"10th_percentile":2471.61,"90th_percentile":6328.18,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":10083.0,"10th_percentile":10083.0,"90th_percentile":10083.0,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":9773.06,"10th_percentile":9773.06,"90th_percentile":10709.75,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":5585.05,"10th_percentile":5585.05,"90th_percentile":5585.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2929.0,"10th_percentile":2929.0,"90th_percentile":2929.0,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3773.51,"10th_percentile":3773.51,"90th_percentile":3773.51,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":9888.82,"10th_percentile":9888.82,"90th_percentile":9888.82,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":7708.27,"10th_percentile":7455.16,"90th_percentile":9585.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":5628.44,"10th_percentile":5628.44,"90th_percentile":5628.44,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":5303.26,"10th_percentile":5303.26,"90th_percentile":15957.95,"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":22895.02,"10th_percentile":22895.02,"90th_percentile":22895.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":15004.3,"10th_percentile":15004.3,"90th_percentile":15004.3,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":16771.44,"10th_percentile":16771.44,"90th_percentile":16771.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":12501.87,"10th_percentile":12501.87,"90th_percentile":12501.87,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6481.38,"10th_percentile":6481.38,"90th_percentile":6481.38,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":18085.85,"10th_percentile":18085.85,"90th_percentile":18085.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":21339.27,"10th_percentile":21339.27,"90th_percentile":37262.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":14721.79,"10th_percentile":14721.79,"90th_percentile":14721.79,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":554.12,"10th_percentile":472.48,"90th_percentile":1117.09,"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"12","median_amount":4198.32,"10th_percentile":1166.89,"90th_percentile":5769.38,"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":"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"17","median_amount":5247.9,"10th_percentile":2351.04,"90th_percentile":6207.31,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":383.61,"10th_percentile":165.47,"90th_percentile":1101.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":1849.81,"10th_percentile":1731.78,"90th_percentile":2590.99,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":9611.44,"10th_percentile":9611.44,"90th_percentile":19857.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"12","median_amount":500.07,"10th_percentile":221.64,"90th_percentile":1222.96,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Musculoskeletal Procedures","code_information":[{"code":"5111","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":1289.6,"10th_percentile":1289.6,"90th_percentile":1289.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1096.38,"10th_percentile":1096.38,"90th_percentile":1096.38,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":1372.57,"10th_percentile":1372.57,"90th_percentile":1381.54,"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 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"11","median_amount":3441.31,"10th_percentile":2134.0,"90th_percentile":5225.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":3916.8,"10th_percentile":3403.13,"90th_percentile":5696.48,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":4424.42,"10th_percentile":4424.42,"90th_percentile":4424.42,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":1348.91,"10th_percentile":1284.0,"90th_percentile":5443.95,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2171.04,"10th_percentile":2171.04,"90th_percentile":2171.04,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3256.56,"10th_percentile":3256.56,"90th_percentile":3256.56,"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":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":3494.27,"10th_percentile":2707.78,"90th_percentile":5674.29,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":1320.94,"10th_percentile":1207.91,"90th_percentile":2462.82,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":12345.21,"10th_percentile":11477.97,"90th_percentile":29346.55,"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":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":3631.42,"10th_percentile":2967.44,"90th_percentile":4269.65,"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"38","median_amount":11432.25,"10th_percentile":9572.47,"90th_percentile":17316.21,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"34","median_amount":7955.0,"10th_percentile":6359.65,"90th_percentile":11644.01,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":17618.03,"10th_percentile":10650.08,"90th_percentile":26824.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":25295.6,"10th_percentile":25295.6,"90th_percentile":25295.6,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"17","median_amount":4214.41,"10th_percentile":3395.65,"90th_percentile":7557.04,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5303.19,"10th_percentile":5303.19,"90th_percentile":5303.19,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":3939.17,"10th_percentile":3535.46,"90th_percentile":5303.19,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3742.82,"10th_percentile":3742.82,"90th_percentile":3742.82,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":4108.57,"10th_percentile":4108.57,"90th_percentile":4108.57,"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":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":7280.69,"10th_percentile":6755.94,"90th_percentile":8945.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"49","median_amount":10594.59,"10th_percentile":6698.54,"90th_percentile":19709.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"25","median_amount":4606.38,"10th_percentile":3422.73,"90th_percentile":9524.19,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":27379.34,"10th_percentile":25875.5,"90th_percentile":66347.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":13126.6,"10th_percentile":12686.67,"90th_percentile":16382.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"22","median_amount":29522.4,"10th_percentile":23032.15,"90th_percentile":36088.55,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"17","median_amount":26278.33,"10th_percentile":21750.5,"90th_percentile":36241.16,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":27888.41,"10th_percentile":27888.41,"90th_percentile":28520.39,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"11","median_amount":10815.05,"10th_percentile":8563.62,"90th_percentile":13995.64,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":11424.26,"10th_percentile":11424.26,"90th_percentile":11424.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"16","median_amount":10942.45,"10th_percentile":8854.62,"90th_percentile":14308.53,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3810.74,"10th_percentile":3810.74,"90th_percentile":3810.74,"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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":20987.74,"10th_percentile":20987.74,"90th_percentile":20987.74,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"21","median_amount":33928.58,"10th_percentile":20507.46,"90th_percentile":58889.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":10796.47,"10th_percentile":9908.34,"90th_percentile":13064.34,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"1 through 10","median_amount":22807.89,"10th_percentile":22807.89,"90th_percentile":22807.89,"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":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":94286.69,"10th_percentile":94286.69,"90th_percentile":94286.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"20","median_amount":20346.84,"10th_percentile":18069.03,"90th_percentile":24413.93,"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"17","median_amount":35217.44,"10th_percentile":33092.5,"90th_percentile":37558.6,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"22","median_amount":32144.1,"10th_percentile":30736.2,"90th_percentile":36161.51,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":56437.82,"10th_percentile":48877.33,"90th_percentile":63925.72,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"22","median_amount":19324.03,"10th_percentile":17494.4,"90th_percentile":23853.13,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":15357.17,"10th_percentile":15357.17,"90th_percentile":15357.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7847.83,"10th_percentile":7847.83,"90th_percentile":7847.83,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":49840.58,"10th_percentile":37580.82,"90th_percentile":58476.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":53689.15,"10th_percentile":51361.16,"90th_percentile":66284.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"58","median_amount":20288.74,"10th_percentile":17502.79,"90th_percentile":28006.41,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":75768.94,"10th_percentile":75768.94,"90th_percentile":75768.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":24984.94,"10th_percentile":24984.94,"90th_percentile":24984.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":42429.22,"10th_percentile":42429.22,"90th_percentile":42429.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":23660.89,"10th_percentile":23335.43,"90th_percentile":26764.41,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"12","median_amount":25862.19,"10th_percentile":24784.08,"90th_percentile":28529.97,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Airway Endoscopy","code_information":[{"code":"5153","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":164.87,"10th_percentile":164.87,"90th_percentile":164.87,"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 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 ENT Procedures","code_information":[{"code":"5162","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":1987.0,"10th_percentile":1987.0,"90th_percentile":1987.0,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 ENT Procedures","code_information":[{"code":"5163","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":7869.5,"10th_percentile":7869.5,"90th_percentile":7869.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":3797.61,"10th_percentile":3797.61,"90th_percentile":3797.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3474.52,"10th_percentile":3474.52,"90th_percentile":3474.52,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1010.46,"10th_percentile":1010.46,"90th_percentile":1010.46,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":5683.66,"10th_percentile":5683.66,"90th_percentile":5683.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 ENT Procedures","code_information":[{"code":"5164","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":8193.49,"10th_percentile":8193.49,"90th_percentile":8193.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":8542.51,"10th_percentile":5695.0,"90th_percentile":11390.0,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":9494.0,"10th_percentile":9012.52,"90th_percentile":9494.0,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":24234.01,"10th_percentile":24234.01,"90th_percentile":24234.01,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":15969.88,"10th_percentile":15969.88,"90th_percentile":15969.88,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5252.76,"10th_percentile":5252.76,"90th_percentile":5252.76,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4673.67,"10th_percentile":3515.5,"90th_percentile":10745.78,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":17088.26,"10th_percentile":11322.03,"90th_percentile":21687.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":8343.16,"10th_percentile":8343.16,"90th_percentile":8343.16,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 5 ENT Procedures","code_information":[{"code":"5165","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":14836.82,"10th_percentile":14488.9,"90th_percentile":18121.05,"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 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":13811.21,"10th_percentile":12115.65,"90th_percentile":16354.75,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":17793.47,"10th_percentile":17793.47,"90th_percentile":17793.47,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":14445.97,"10th_percentile":14445.97,"90th_percentile":14445.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3515.5,"10th_percentile":3220.07,"90th_percentile":5252.76,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":674.04,"10th_percentile":674.04,"90th_percentile":674.04,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":11715.73,"10th_percentile":11715.73,"90th_percentile":12692.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Vascular Procedures","code_information":[{"code":"5181","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":978.59,"10th_percentile":978.59,"90th_percentile":978.59,"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 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":2855.27,"10th_percentile":2855.27,"90th_percentile":2855.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":855.8,"10th_percentile":855.8,"90th_percentile":890.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":1788.55,"10th_percentile":1788.55,"90th_percentile":1788.55,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Vascular Procedures","code_information":[{"code":"5182","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":6409.41,"10th_percentile":6409.41,"90th_percentile":6409.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":55.0,"10th_percentile":55.0,"90th_percentile":55.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":4678.48,"10th_percentile":4678.48,"90th_percentile":4678.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":13125.0,"10th_percentile":13125.0,"90th_percentile":13125.0,"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. Ungroupable ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":4801.35,"10th_percentile":4801.35,"90th_percentile":4801.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":3635.0,"10th_percentile":3635.0,"90th_percentile":3635.0,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":25907.59,"10th_percentile":25907.59,"90th_percentile":25907.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":8240.55,"10th_percentile":8240.55,"90th_percentile":8240.55,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":5201.69,"10th_percentile":5201.69,"90th_percentile":7342.86,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":4711.45,"10th_percentile":4711.45,"90th_percentile":4711.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":4196.99,"10th_percentile":4196.99,"90th_percentile":4196.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":1367.16,"10th_percentile":1367.16,"90th_percentile":2128.96,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":944.61,"10th_percentile":944.61,"90th_percentile":944.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":19375.27,"10th_percentile":19375.27,"90th_percentile":19375.27,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":1531.28,"10th_percentile":1375.89,"90th_percentile":1768.99,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3345.74,"10th_percentile":3345.74,"90th_percentile":3345.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3258.31,"10th_percentile":3258.31,"90th_percentile":3258.31,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":10866.59,"10th_percentile":10866.59,"90th_percentile":10866.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"15","median_amount":1724.54,"10th_percentile":954.42,"90th_percentile":3410.91,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":15532.32,"10th_percentile":12549.3,"90th_percentile":17604.76,"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":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":3775.89,"10th_percentile":3081.18,"90th_percentile":6177.46,"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":"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"17","median_amount":4612.0,"10th_percentile":3883.26,"90th_percentile":6918.0,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"27","median_amount":2843.03,"10th_percentile":2584.06,"90th_percentile":4588.5,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":18610.85,"10th_percentile":18610.85,"90th_percentile":18610.85,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":13617.03,"10th_percentile":13617.03,"90th_percentile":13617.03,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":5493.2,"10th_percentile":5493.2,"90th_percentile":5799.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1198.96,"10th_percentile":1198.96,"90th_percentile":3262.0,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1644.87,"10th_percentile":1636.13,"90th_percentile":3262.0,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":7189.58,"10th_percentile":7189.58,"90th_percentile":7189.58,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":13728.1,"10th_percentile":7192.5,"90th_percentile":15505.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3262.0,"10th_percentile":3262.0,"90th_percentile":3262.0,"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":"[All Other OP (%BC): 28]","count":"15","median_amount":4258.4,"10th_percentile":3403.36,"90th_percentile":5562.71,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Upper GI Procedures","code_information":[{"code":"5302","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":17517.29,"10th_percentile":17517.29,"90th_percentile":17517.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":4650.35,"10th_percentile":4450.03,"90th_percentile":7571.6,"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 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":7321.24,"10th_percentile":5695.0,"90th_percentile":38209.9,"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 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":6320.38,"10th_percentile":6220.21,"90th_percentile":11078.38,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":6719.73,"10th_percentile":5893.07,"90th_percentile":6915.7,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1636.13,"10th_percentile":1636.13,"90th_percentile":3272.26,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3272.26,"10th_percentile":3272.26,"90th_percentile":3272.26,"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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":7394.38,"10th_percentile":7394.38,"90th_percentile":7394.38,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":12746.4,"10th_percentile":12746.4,"90th_percentile":16350.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":4650.94,"10th_percentile":3915.82,"90th_percentile":7252.44,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":8001.17,"10th_percentile":5431.53,"90th_percentile":8696.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"11","median_amount":2998.98,"10th_percentile":2832.44,"90th_percentile":3266.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"47","median_amount":4612.0,"10th_percentile":4390.0,"90th_percentile":4612.01,"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 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"35","median_amount":3059.0,"10th_percentile":2210.85,"90th_percentile":3059.01,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":8074.17,"10th_percentile":7824.45,"90th_percentile":10321.29,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":7038.67,"10th_percentile":7038.67,"90th_percentile":7038.67,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"19","median_amount":2852.85,"10th_percentile":2689.79,"90th_percentile":4369.29,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1625.87,"10th_percentile":1625.87,"90th_percentile":1625.87,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":2714.25,"10th_percentile":2714.25,"90th_percentile":2714.25,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"16","median_amount":1625.87,"10th_percentile":1598.88,"90th_percentile":1634.77,"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":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":4666.72,"10th_percentile":4666.72,"90th_percentile":4807.18,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"51","median_amount":7223.05,"10th_percentile":6562.36,"90th_percentile":8888.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"39","median_amount":2994.63,"10th_percentile":2781.15,"90th_percentile":5566.43,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":17284.33,"10th_percentile":10635.07,"90th_percentile":21325.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"19","median_amount":3682.18,"10th_percentile":3478.48,"90th_percentile":6180.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"50","median_amount":5695.0,"10th_percentile":5464.88,"90th_percentile":8542.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"56","median_amount":4747.0,"10th_percentile":4518.0,"90th_percentile":7120.5,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":10542.79,"10th_percentile":10059.84,"90th_percentile":12177.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":10226.04,"10th_percentile":8365.28,"90th_percentile":13327.72,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"34","median_amount":3772.72,"10th_percentile":3445.99,"90th_percentile":5504.71,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1629.17,"10th_percentile":1625.87,"90th_percentile":3265.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":5128.4,"10th_percentile":5128.4,"90th_percentile":5128.4,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1625.87,"10th_percentile":1625.87,"90th_percentile":3270.9,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":633.18,"10th_percentile":633.18,"90th_percentile":633.18,"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":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1625.87,"10th_percentile":1625.87,"90th_percentile":1625.87,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":6611.03,"10th_percentile":6324.84,"90th_percentile":8577.68,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"47","median_amount":9657.4,"10th_percentile":8372.28,"90th_percentile":15729.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"57","median_amount":3845.03,"10th_percentile":3570.97,"90th_percentile":5993.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"1 through 10","median_amount":11601.78,"10th_percentile":11601.78,"90th_percentile":11601.78,"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 Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":2868.78,"10th_percentile":2868.78,"90th_percentile":2868.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":20303.74,"10th_percentile":20303.74,"90th_percentile":20303.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":5675.7,"10th_percentile":5675.7,"90th_percentile":5675.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":10796.22,"10th_percentile":10796.22,"90th_percentile":16550.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":8842.95,"10th_percentile":8842.95,"90th_percentile":8842.95,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":6856.88,"10th_percentile":6856.88,"90th_percentile":6856.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":790.81,"10th_percentile":790.81,"90th_percentile":790.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":8989.94,"10th_percentile":8989.94,"90th_percentile":8989.94,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":15989.63,"10th_percentile":12255.08,"90th_percentile":20005.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":5454.75,"10th_percentile":4977.41,"90th_percentile":10736.3,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","code_information":[{"code":"5342","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":8089.97,"10th_percentile":8089.97,"90th_percentile":8089.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Laparoscopy and Related Services","code_information":[{"code":"5361","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":32522.29,"10th_percentile":29243.86,"90th_percentile":49657.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":9718.57,"10th_percentile":9718.57,"90th_percentile":9718.57,"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"24","median_amount":19370.0,"10th_percentile":15926.8,"90th_percentile":21664.39,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"13","median_amount":15286.0,"10th_percentile":13846.08,"90th_percentile":19369.99,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":21168.44,"10th_percentile":21168.44,"90th_percentile":21168.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":16113.57,"10th_percentile":16113.57,"90th_percentile":16113.57,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":8642.4,"10th_percentile":8642.4,"90th_percentile":8642.4,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8882.82,"10th_percentile":8882.82,"90th_percentile":8882.82,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7979.71,"10th_percentile":5930.45,"90th_percentile":12606.75,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":11904.41,"10th_percentile":11904.41,"90th_percentile":11904.41,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"15","median_amount":26318.8,"10th_percentile":16830.83,"90th_percentile":44596.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9013.27,"10th_percentile":9013.27,"90th_percentile":9103.31,"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":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":5338.04,"10th_percentile":5023.06,"90th_percentile":6269.05,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Laparoscopy and Related Services","code_information":[{"code":"5362","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":23705.0,"10th_percentile":23705.0,"90th_percentile":23705.0,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":19673.22,"10th_percentile":19673.22,"90th_percentile":28185.0,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9546.92,"10th_percentile":9546.92,"90th_percentile":9546.92,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":25495.8,"10th_percentile":25495.8,"90th_percentile":40364.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":245.59,"10th_percentile":200.05,"90th_percentile":340.32,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Gynecologic Procedures","code_information":[{"code":"5411","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":4198.61,"10th_percentile":4198.61,"90th_percentile":4198.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"12","median_amount":2006.35,"10th_percentile":1498.19,"90th_percentile":2326.0,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":2227.87,"10th_percentile":961.21,"90th_percentile":2841.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":4358.89,"10th_percentile":4358.89,"90th_percentile":4358.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2304.37,"10th_percentile":2304.37,"90th_percentile":2304.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":376.4,"10th_percentile":314.02,"90th_percentile":860.54,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":2792.42,"10th_percentile":2522.41,"90th_percentile":3838.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Gynecologic Procedures","code_information":[{"code":"5412","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":12943.97,"10th_percentile":12943.97,"90th_percentile":12943.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":10798.03,"10th_percentile":10798.03,"90th_percentile":10798.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"14","median_amount":5695.0,"10th_percentile":4988.92,"90th_percentile":7790.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":4747.01,"10th_percentile":4747.0,"90th_percentile":6276.49,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":27301.32,"10th_percentile":27301.32,"90th_percentile":27301.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":9806.48,"10th_percentile":9806.48,"90th_percentile":9806.48,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4716.6,"10th_percentile":4716.6,"90th_percentile":4716.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4516.63,"10th_percentile":4516.63,"90th_percentile":5102.9,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":10569.59,"10th_percentile":10569.59,"90th_percentile":10569.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":15556.58,"10th_percentile":11123.52,"90th_percentile":22831.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":6549.03,"10th_percentile":6549.03,"90th_percentile":6549.03,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":28084.02,"10th_percentile":28084.02,"90th_percentile":28084.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":18140.98,"10th_percentile":18140.98,"90th_percentile":18140.98,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":21881.39,"10th_percentile":21881.39,"90th_percentile":21881.39,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":29176.45,"10th_percentile":29176.45,"90th_percentile":29176.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":15361.3,"10th_percentile":15361.3,"90th_percentile":15361.3,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":8555.19,"10th_percentile":8555.19,"90th_percentile":8555.19,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9237.49,"10th_percentile":9237.49,"90th_percentile":9237.49,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":13124.73,"10th_percentile":13124.73,"90th_percentile":26898.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":5420.07,"10th_percentile":5420.07,"90th_percentile":5456.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"13","median_amount":1927.96,"10th_percentile":1468.96,"90th_percentile":2614.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"12","median_amount":5694.99,"10th_percentile":4410.49,"90th_percentile":8131.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"14","median_amount":5983.58,"10th_percentile":4118.16,"90th_percentile":8275.45,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":1550.82,"10th_percentile":630.43,"90th_percentile":2587.82,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3042.65,"10th_percentile":3042.65,"90th_percentile":3288.9,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":4779.58,"10th_percentile":2723.21,"90th_percentile":4788.48,"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":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":944.05,"10th_percentile":944.05,"90th_percentile":944.05,"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":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":2403.82,"10th_percentile":2403.82,"90th_percentile":2431.46,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"25","median_amount":4758.15,"10th_percentile":3119.44,"90th_percentile":5041.99,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"30","median_amount":1825.16,"10th_percentile":1300.44,"90th_percentile":2066.81,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Nerve Injections","code_information":[{"code":"5441","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":495.02,"10th_percentile":251.23,"90th_percentile":1007.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"14","median_amount":1722.42,"10th_percentile":1336.65,"90th_percentile":1930.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"11","median_amount":1846.29,"10th_percentile":1705.17,"90th_percentile":2052.87,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":1506.88,"10th_percentile":1506.88,"90th_percentile":1506.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":561.38,"10th_percentile":209.77,"90th_percentile":2622.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":511.63,"10th_percentile":511.26,"90th_percentile":525.97,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":403.71,"10th_percentile":399.37,"90th_percentile":942.29,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":730.25,"10th_percentile":730.25,"90th_percentile":853.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"23","median_amount":1324.51,"10th_percentile":400.23,"90th_percentile":1390.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"19","median_amount":508.87,"10th_percentile":306.64,"90th_percentile":955.9,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"1 through 10","median_amount":1167.3,"10th_percentile":1167.3,"90th_percentile":1167.3,"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":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Nerve Injections","code_information":[{"code":"5442","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":2791.16,"10th_percentile":2791.16,"90th_percentile":2791.16,"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":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"26","median_amount":1029.77,"10th_percentile":805.86,"90th_percentile":1537.95,"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":3671.33,"10th_percentile":3459.58,"90th_percentile":3898.13,"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":"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"11","median_amount":2819.36,"10th_percentile":1891.0,"90th_percentile":3059.0,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2427.87,"10th_percentile":2427.87,"90th_percentile":2427.87,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"18","median_amount":1132.19,"10th_percentile":816.72,"90th_percentile":1884.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":1242.5,"10th_percentile":1239.38,"90th_percentile":1251.4,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":501.7,"10th_percentile":501.7,"90th_percentile":501.7,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":2614.66,"10th_percentile":457.73,"90th_percentile":9338.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"50","median_amount":1080.61,"10th_percentile":785.17,"90th_percentile":1852.62,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Nerve Injections","code_information":[{"code":"5443","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":4006.41,"10th_percentile":4006.41,"90th_percentile":4006.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"23","median_amount":1871.1,"10th_percentile":1047.23,"90th_percentile":2407.01,"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":3528.64,"10th_percentile":3344.9,"90th_percentile":7099.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"16","median_amount":5218.5,"10th_percentile":3456.94,"90th_percentile":7795.99,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":5893.63,"10th_percentile":5893.63,"90th_percentile":5893.63,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":5168.26,"10th_percentile":5168.26,"90th_percentile":5168.26,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"26","median_amount":1733.2,"10th_percentile":1092.56,"90th_percentile":2060.02,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3727.5,"10th_percentile":1867.05,"90th_percentile":4346.73,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"36","median_amount":4181.98,"10th_percentile":1251.4,"90th_percentile":4348.75,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":490.84,"10th_percentile":490.84,"90th_percentile":490.84,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":3776.62,"10th_percentile":3776.62,"90th_percentile":3776.62,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"19","median_amount":2864.13,"10th_percentile":943.1,"90th_percentile":6030.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"64","median_amount":1859.3,"10th_percentile":1068.46,"90th_percentile":2245.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"1 through 10","median_amount":824.55,"10th_percentile":824.55,"90th_percentile":824.55,"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."}]}]},{"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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":3429.04,"10th_percentile":3429.04,"90th_percentile":3429.04,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Neurostimulator and Related Procedures","code_information":[{"code":"5462","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":15244.74,"10th_percentile":15244.74,"90th_percentile":15244.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":14880.47,"10th_percentile":14880.47,"90th_percentile":14880.47,"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":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":11862.7,"10th_percentile":11679.36,"90th_percentile":12748.37,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 5 Neurostimulator and Related Procedures","code_information":[{"code":"5465","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":35577.37,"10th_percentile":35577.37,"90th_percentile":35577.37,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":42323.33,"10th_percentile":39292.69,"90th_percentile":43950.59,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Imaging without Contrast","code_information":[{"code":"5521","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"49","median_amount":443.34,"10th_percentile":329.25,"90th_percentile":908.19,"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":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"184","median_amount":160.2,"10th_percentile":62.47,"90th_percentile":412.14,"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"327","median_amount":130.81,"10th_percentile":99.39,"90th_percentile":292.08,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"334","median_amount":115.29,"10th_percentile":81.48,"90th_percentile":307.63,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"82","median_amount":426.92,"10th_percentile":311.95,"90th_percentile":815.72,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"1 through 10","median_amount":422.69,"10th_percentile":422.69,"90th_percentile":422.69,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"21","median_amount":352.13,"10th_percentile":302.58,"90th_percentile":906.35,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"232","median_amount":157.58,"10th_percentile":52.39,"90th_percentile":448.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"36","median_amount":90.54,"10th_percentile":90.54,"90th_percentile":158.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":120.91,"10th_percentile":120.91,"90th_percentile":128.98,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"230","median_amount":91.09,"10th_percentile":90.54,"90th_percentile":177.57,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":36.88,"10th_percentile":36.88,"90th_percentile":116.25,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":94.16,"10th_percentile":39.69,"90th_percentile":139.66,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":222.34,"10th_percentile":222.34,"90th_percentile":222.34,"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":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"43","median_amount":281.44,"10th_percentile":225.47,"90th_percentile":1020.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"376","median_amount":393.97,"10th_percentile":279.06,"90th_percentile":1235.07,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":90.54,"10th_percentile":90.54,"90th_percentile":231.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"481","median_amount":169.28,"10th_percentile":126.14,"90th_percentile":374.9,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"1 through 10","median_amount":287.93,"10th_percentile":239.63,"90th_percentile":491.26,"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":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"1 through 10","median_amount":283.61,"10th_percentile":283.61,"90th_percentile":283.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."}]}]},{"description":"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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"66","median_amount":1353.43,"10th_percentile":628.07,"90th_percentile":2310.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"166","median_amount":468.56,"10th_percentile":189.36,"90th_percentile":898.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"271","median_amount":874.0,"10th_percentile":135.2,"90th_percentile":2065.96,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"243","median_amount":765.0,"10th_percentile":125.91,"90th_percentile":1935.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"58","median_amount":1344.73,"10th_percentile":625.12,"90th_percentile":2868.74,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"1 through 10","median_amount":2154.5,"10th_percentile":2154.5,"90th_percentile":2154.5,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"34","median_amount":1286.98,"10th_percentile":509.88,"90th_percentile":2572.4,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"190","median_amount":462.39,"10th_percentile":209.84,"90th_percentile":791.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"55","median_amount":173.36,"10th_percentile":127.94,"90th_percentile":309.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":339.22,"10th_percentile":244.02,"90th_percentile":858.85,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"259","median_amount":173.36,"10th_percentile":122.89,"90th_percentile":446.55,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":70.23,"10th_percentile":64.69,"90th_percentile":364.52,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":177.33,"10th_percentile":90.54,"90th_percentile":237.28,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":874.98,"10th_percentile":874.98,"90th_percentile":874.98,"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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"49","median_amount":676.71,"10th_percentile":224.11,"90th_percentile":1655.84,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"359","median_amount":1164.24,"10th_percentile":522.25,"90th_percentile":2345.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":268.98,"10th_percentile":268.98,"90th_percentile":268.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"394","median_amount":448.24,"10th_percentile":201.52,"90th_percentile":838.25,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"1 through 10","median_amount":776.86,"10th_percentile":776.86,"90th_percentile":776.86,"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":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Imaging without Contrast","code_information":[{"code":"5523","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"34","median_amount":5530.14,"10th_percentile":4063.48,"90th_percentile":6409.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"84","median_amount":1827.25,"10th_percentile":653.12,"90th_percentile":2750.96,"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 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"156","median_amount":4053.0,"10th_percentile":2361.56,"90th_percentile":4258.0,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"158","median_amount":3503.0,"10th_percentile":1410.39,"90th_percentile":3700.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"16","median_amount":5757.9,"10th_percentile":3901.14,"90th_percentile":6555.02,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":4426.84,"10th_percentile":4123.51,"90th_percentile":4611.29,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"98","median_amount":1712.3,"10th_percentile":334.6,"90th_percentile":2189.38,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"20","median_amount":391.46,"10th_percentile":390.3,"90th_percentile":2470.86,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":1508.22,"10th_percentile":1508.22,"90th_percentile":1508.22,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"152","median_amount":390.3,"10th_percentile":390.3,"90th_percentile":782.92,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":155.03,"10th_percentile":155.03,"90th_percentile":155.03,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":390.3,"10th_percentile":390.3,"90th_percentile":407.12,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":9222.59,"10th_percentile":9222.59,"90th_percentile":9222.59,"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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":1541.95,"10th_percentile":1541.95,"90th_percentile":1541.95,"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":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"21","median_amount":3174.59,"10th_percentile":1577.84,"90th_percentile":4005.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"190","median_amount":4513.7,"10th_percentile":1655.78,"90th_percentile":6226.71,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"207","median_amount":1858.97,"10th_percentile":357.64,"90th_percentile":3194.07,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"1 through 10","median_amount":1471.65,"10th_percentile":1471.65,"90th_percentile":1471.65,"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 Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"1 through 10","median_amount":3200.74,"10th_percentile":3200.74,"90th_percentile":3200.74,"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":"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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"14","median_amount":1895.07,"10th_percentile":1583.98,"90th_percentile":3353.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"68","median_amount":752.37,"10th_percentile":462.37,"90th_percentile":1885.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"53","median_amount":990.61,"10th_percentile":887.59,"90th_percentile":2712.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":"56","median_amount":998.53,"10th_percentile":891.55,"90th_percentile":2712.39,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"11","median_amount":2170.72,"10th_percentile":1938.14,"90th_percentile":5306.85,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2864.03,"10th_percentile":2864.03,"90th_percentile":2864.03,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"74","median_amount":687.1,"10th_percentile":587.84,"90th_percentile":1851.64,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":764.43,"10th_percentile":702.6,"90th_percentile":1042.7,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":686.12,"10th_percentile":686.12,"90th_percentile":686.12,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"33","median_amount":764.43,"10th_percentile":702.6,"90th_percentile":1042.7,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":278.22,"10th_percentile":278.22,"90th_percentile":278.22,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":1184.42,"10th_percentile":785.22,"90th_percentile":3080.92,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"67","median_amount":1684.03,"10th_percentile":1347.22,"90th_percentile":3878.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1464.36,"10th_percentile":1464.36,"90th_percentile":1464.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"139","median_amount":689.12,"10th_percentile":518.57,"90th_percentile":1886.88,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"1 through 10","median_amount":663.26,"10th_percentile":663.26,"90th_percentile":663.26,"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."}]}]},{"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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":6240.39,"10th_percentile":3048.22,"90th_percentile":8079.95,"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":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"45","median_amount":3505.4,"10th_percentile":967.21,"90th_percentile":4027.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"31","median_amount":3252.25,"10th_percentile":1002.16,"90th_percentile":3452.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":"28","median_amount":2629.24,"10th_percentile":651.01,"90th_percentile":2877.0,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":3275.43,"10th_percentile":2326.24,"90th_percentile":9483.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"1 through 10","median_amount":8653.35,"10th_percentile":3221.0,"90th_percentile":9097.4,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":7952.08,"10th_percentile":7952.08,"90th_percentile":7952.08,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"52","median_amount":3042.97,"10th_percentile":787.45,"90th_percentile":3534.36,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":1063.44,"10th_percentile":527.54,"90th_percentile":1080.51,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"16","median_amount":1068.19,"10th_percentile":522.25,"90th_percentile":1158.89,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":1647.58,"10th_percentile":1589.03,"90th_percentile":5493.43,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"35","median_amount":4925.79,"10th_percentile":1356.66,"90th_percentile":9101.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"99","median_amount":2890.47,"10th_percentile":555.16,"90th_percentile":3768.42,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"11","median_amount":6616.91,"10th_percentile":5896.95,"90th_percentile":10335.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"38","median_amount":2239.05,"10th_percentile":1711.35,"90th_percentile":4127.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"90","median_amount":3619.3,"10th_percentile":2234.0,"90th_percentile":4321.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":"80","median_amount":3210.03,"10th_percentile":1862.1,"90th_percentile":3737.33,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"14","median_amount":5854.28,"10th_percentile":5669.47,"90th_percentile":9498.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"1 through 10","median_amount":9168.76,"10th_percentile":9168.76,"90th_percentile":9168.76,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":5577.1,"10th_percentile":5576.29,"90th_percentile":6000.66,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"52","median_amount":2299.3,"10th_percentile":1977.36,"90th_percentile":3454.75,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":656.47,"10th_percentile":522.25,"90th_percentile":797.93,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":1727.13,"10th_percentile":1727.13,"90th_percentile":1727.13,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"77","median_amount":656.47,"10th_percentile":522.25,"90th_percentile":1188.26,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":261.57,"10th_percentile":261.57,"90th_percentile":261.57,"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":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"24","median_amount":3729.25,"10th_percentile":3208.46,"90th_percentile":6942.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"95","median_amount":5779.44,"10th_percentile":4220.91,"90th_percentile":10239.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"113","median_amount":2406.25,"10th_percentile":1836.64,"90th_percentile":4168.9,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"1 through 10","median_amount":1774.21,"10th_percentile":1774.21,"90th_percentile":1774.21,"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 Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Imaging with Contrast","code_information":[{"code":"5573","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":8047.14,"10th_percentile":8047.14,"90th_percentile":8047.14,"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":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":1110.12,"10th_percentile":1110.12,"90th_percentile":1110.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":4808.18,"10th_percentile":2899.19,"90th_percentile":9051.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":7378.0,"10th_percentile":1290.0,"90th_percentile":8531.96,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1552.57,"10th_percentile":1552.57,"90th_percentile":1552.57,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":391.45,"10th_percentile":391.45,"90th_percentile":391.45,"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":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":5709.98,"10th_percentile":2627.26,"90th_percentile":10646.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":1423.9,"10th_percentile":1301.99,"90th_percentile":1919.5,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Nuclear Medicine and Related Services","code_information":[{"code":"5591","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":794.77,"10th_percentile":794.77,"90th_percentile":794.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":1175.04,"10th_percentile":1175.04,"90th_percentile":1175.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":1415.9,"10th_percentile":1415.9,"90th_percentile":1415.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":7700.38,"10th_percentile":7700.38,"90th_percentile":7700.38,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1697.62,"10th_percentile":1697.62,"90th_percentile":1697.62,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":3485.15,"10th_percentile":3485.15,"90th_percentile":3485.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":1025.68,"10th_percentile":1025.68,"90th_percentile":1025.68,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Nuclear Medicine and Related Services","code_information":[{"code":"5592","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":3380.07,"10th_percentile":3380.07,"90th_percentile":3380.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":1296.44,"10th_percentile":1296.44,"90th_percentile":1296.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":406.59,"10th_percentile":406.59,"90th_percentile":406.59,"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":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":1997.13,"10th_percentile":1997.13,"90th_percentile":1997.13,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":2861.32,"10th_percentile":2775.45,"90th_percentile":3522.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":936.61,"10th_percentile":936.61,"90th_percentile":936.61,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Nuclear Medicine and Related Services","code_information":[{"code":"5593","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":6476.93,"10th_percentile":6476.93,"90th_percentile":7594.57,"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":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"21","median_amount":2799.35,"10th_percentile":2258.88,"90th_percentile":3005.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"27","median_amount":2338.84,"10th_percentile":1925.64,"90th_percentile":10280.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":"19","median_amount":1976.46,"10th_percentile":1581.17,"90th_percentile":9319.03,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":7244.71,"10th_percentile":5415.58,"90th_percentile":11488.96,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":4797.52,"10th_percentile":4797.52,"90th_percentile":4797.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"26","median_amount":2740.03,"10th_percentile":2308.83,"90th_percentile":3243.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1759.76,"10th_percentile":1759.76,"90th_percentile":1759.76,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1759.76,"10th_percentile":1696.81,"90th_percentile":2261.81,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":811.09,"10th_percentile":811.09,"90th_percentile":811.09,"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":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":3207.97,"10th_percentile":3207.97,"90th_percentile":3693.49,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"21","median_amount":5251.47,"10th_percentile":2291.9,"90th_percentile":7338.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1481.49,"10th_percentile":1481.49,"90th_percentile":1481.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"42","median_amount":2944.64,"10th_percentile":2487.76,"90th_percentile":3045.95,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Nuclear Medicine and Related Services","code_information":[{"code":"5594","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":8704.91,"10th_percentile":8704.91,"90th_percentile":8754.52,"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":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":2856.59,"10th_percentile":2456.54,"90th_percentile":7013.92,"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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"13","median_amount":7306.9,"10th_percentile":7233.31,"90th_percentile":7627.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":6008.89,"10th_percentile":5408.0,"90th_percentile":11350.09,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":19110.7,"10th_percentile":19110.7,"90th_percentile":19110.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":6507.49,"10th_percentile":6507.49,"90th_percentile":6507.49,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"16","median_amount":2512.82,"10th_percentile":2111.58,"90th_percentile":4877.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2291.38,"10th_percentile":2291.38,"90th_percentile":2291.38,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":2779.53,"10th_percentile":2779.53,"90th_percentile":2779.53,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2272.44,"10th_percentile":2164.6,"90th_percentile":2272.44,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":857.24,"10th_percentile":857.24,"90th_percentile":857.24,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"13","median_amount":7123.26,"10th_percentile":6603.26,"90th_percentile":8465.29,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"21","median_amount":2914.89,"10th_percentile":2734.49,"90th_percentile":6705.45,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Pathology","code_information":[{"code":"5671","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"25","median_amount":371.59,"10th_percentile":371.59,"90th_percentile":743.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"64","median_amount":132.42,"10th_percentile":132.42,"90th_percentile":325.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"136","median_amount":32.38,"10th_percentile":28.79,"90th_percentile":64.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":"116","median_amount":32.38,"10th_percentile":25.91,"90th_percentile":115.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"16","median_amount":380.03,"10th_percentile":323.03,"90th_percentile":883.13,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"1 through 10","median_amount":354.28,"10th_percentile":354.28,"90th_percentile":708.55,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"15","median_amount":301.66,"10th_percentile":301.66,"90th_percentile":741.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"113","median_amount":124.15,"10th_percentile":124.15,"90th_percentile":305.02,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3264.46,"10th_percentile":3264.46,"90th_percentile":3264.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":265.59,"10th_percentile":265.59,"90th_percentile":265.59,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"32","median_amount":53.01,"10th_percentile":53.01,"90th_percentile":95.58,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"11","median_amount":232.24,"10th_percentile":201.71,"90th_percentile":464.49,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"143","median_amount":330.21,"10th_percentile":264.17,"90th_percentile":875.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"163","median_amount":135.12,"10th_percentile":126.68,"90th_percentile":271.61,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"1 through 10","median_amount":233.24,"10th_percentile":233.24,"90th_percentile":373.18,"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 Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Pathology","code_information":[{"code":"5672","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":106.44,"10th_percentile":106.44,"90th_percentile":106.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":453.96,"10th_percentile":329.15,"90th_percentile":1127.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"11","median_amount":154.09,"10th_percentile":86.47,"90th_percentile":540.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":174.69,"10th_percentile":96.06,"90th_percentile":336.09,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":1762.24,"10th_percentile":1762.24,"90th_percentile":3701.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2065.17,"10th_percentile":1398.83,"90th_percentile":3296.59,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"15","median_amount":575.67,"10th_percentile":275.52,"90th_percentile":1044.84,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":340.92,"10th_percentile":323.31,"90th_percentile":453.38,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":1640.63,"10th_percentile":1640.63,"90th_percentile":1765.13,"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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":861.54,"10th_percentile":861.54,"90th_percentile":861.54,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"24","median_amount":1462.22,"10th_percentile":732.84,"90th_percentile":2594.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"35","median_amount":335.87,"10th_percentile":229.9,"90th_percentile":587.42,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Pathology","code_information":[{"code":"5673","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":940.12,"10th_percentile":940.12,"90th_percentile":940.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":1008.88,"10th_percentile":1008.88,"90th_percentile":1008.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":287.84,"10th_percentile":287.84,"90th_percentile":654.39,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":732.99,"10th_percentile":732.99,"90th_percentile":732.99,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":282.94,"10th_percentile":8.03,"90th_percentile":454.01,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":2432.19,"10th_percentile":837.19,"90th_percentile":5730.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":1128.51,"10th_percentile":1128.51,"90th_percentile":1128.51,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Pathology","code_information":[{"code":"5674","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":3799.64,"10th_percentile":3799.64,"90th_percentile":4468.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":1253.73,"10th_percentile":1253.73,"90th_percentile":1253.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. 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Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":1880.66,"10th_percentile":1880.66,"90th_percentile":1880.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":4217.06,"10th_percentile":2027.43,"90th_percentile":5706.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":508.33,"10th_percentile":508.33,"90th_percentile":508.33,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":7983.57,"10th_percentile":7983.57,"90th_percentile":7983.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":3892.9,"10th_percentile":3892.9,"90th_percentile":3892.9,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":16.28,"10th_percentile":10.75,"90th_percentile":7110.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":3172.85,"10th_percentile":3172.85,"90th_percentile":3172.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":11366.0,"10th_percentile":11366.0,"90th_percentile":11366.0,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":11449.09,"10th_percentile":11449.09,"90th_percentile":11449.09,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":15313.49,"10th_percentile":15313.49,"90th_percentile":15313.49,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3669.23,"10th_percentile":3669.23,"90th_percentile":3669.23,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":19213.43,"10th_percentile":19213.43,"90th_percentile":19213.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1857.35,"10th_percentile":1857.35,"90th_percentile":1857.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":12557.46,"10th_percentile":12557.46,"90th_percentile":18192.7,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":2887.73,"10th_percentile":2887.73,"90th_percentile":2887.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"19","median_amount":2475.38,"10th_percentile":1944.1,"90th_percentile":5196.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"19","median_amount":590.33,"10th_percentile":138.98,"90th_percentile":4307.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":2343.73,"10th_percentile":2343.73,"90th_percentile":2343.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":1848.65,"10th_percentile":151.1,"90th_percentile":2360.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"18","median_amount":303.78,"10th_percentile":217.03,"90th_percentile":1525.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"13","median_amount":1926.39,"10th_percentile":71.82,"90th_percentile":3411.97,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":2818.11,"10th_percentile":1591.06,"90th_percentile":5111.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":2121.08,"10th_percentile":2121.08,"90th_percentile":2198.9,"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"30","median_amount":756.0,"10th_percentile":18.17,"90th_percentile":5901.16,"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 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"39","median_amount":683.0,"10th_percentile":271.66,"90th_percentile":13030.27,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":4186.34,"10th_percentile":3170.66,"90th_percentile":7728.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":9914.16,"10th_percentile":9914.16,"90th_percentile":9914.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"15","median_amount":530.1,"10th_percentile":263.62,"90th_percentile":8025.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1489.63,"10th_percentile":209.82,"90th_percentile":10944.29,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":386.9,"10th_percentile":378.54,"90th_percentile":4931.71,"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":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":78.14,"10th_percentile":78.14,"90th_percentile":78.14,"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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":20087.98,"10th_percentile":20087.98,"90th_percentile":20087.98,"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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":12668.18,"10th_percentile":12668.18,"90th_percentile":12668.18,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"26","median_amount":954.2,"10th_percentile":622.9,"90th_percentile":5824.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6383.7,"10th_percentile":6383.7,"90th_percentile":6383.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"29","median_amount":7186.66,"10th_percentile":1136.57,"90th_percentile":9418.7,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"1 through 10","median_amount":1785.87,"10th_percentile":1785.87,"90th_percentile":1785.87,"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":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Drug Administration","code_information":[{"code":"5694","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":1310.52,"10th_percentile":1310.52,"90th_percentile":1310.52,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":513.76,"10th_percentile":513.76,"90th_percentile":513.76,"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":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":256.32,"10th_percentile":256.32,"90th_percentile":256.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"13","median_amount":729.77,"10th_percentile":620.31,"90th_percentile":1247.31,"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 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"16","median_amount":729.77,"10th_percentile":693.28,"90th_percentile":1113.67,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":735.61,"10th_percentile":735.61,"90th_percentile":1745.29,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":521.35,"10th_percentile":521.35,"90th_percentile":521.35,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":240.3,"10th_percentile":240.3,"90th_percentile":18790.79,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":249.57,"10th_percentile":246.32,"90th_percentile":249.57,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":99.7,"10th_percentile":99.7,"90th_percentile":99.7,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":249.57,"10th_percentile":249.57,"90th_percentile":249.57,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"25","median_amount":570.68,"10th_percentile":435.45,"90th_percentile":915.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":233.53,"10th_percentile":233.53,"90th_percentile":233.53,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":1180.08,"10th_percentile":1149.45,"90th_percentile":2830.28,"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":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"16","median_amount":422.84,"10th_percentile":406.96,"90th_percentile":519.68,"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"26","median_amount":754.28,"10th_percentile":575.91,"90th_percentile":1284.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"18","median_amount":691.31,"10th_percentile":379.98,"90th_percentile":1231.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":1485.55,"10th_percentile":1485.55,"90th_percentile":2513.72,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"1 through 10","median_amount":1044.9,"10th_percentile":1044.9,"90th_percentile":1044.9,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":1912.51,"10th_percentile":1912.51,"90th_percentile":1912.51,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"13","median_amount":406.39,"10th_percentile":323.07,"90th_percentile":486.9,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":278.27,"10th_percentile":278.27,"90th_percentile":278.27,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":400.28,"10th_percentile":353.05,"90th_percentile":573.64,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":136.45,"10th_percentile":136.45,"90th_percentile":139.48,"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":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":150.1,"10th_percentile":150.1,"90th_percentile":150.1,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":1278.84,"10th_percentile":1236.81,"90th_percentile":1472.39,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"31","median_amount":1154.79,"10th_percentile":414.17,"90th_percentile":2093.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"30","median_amount":429.12,"10th_percentile":357.21,"90th_percentile":537.33,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"1 through 10","median_amount":403.79,"10th_percentile":403.79,"90th_percentile":403.79,"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."}]}]},{"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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":1099.67,"10th_percentile":1099.67,"90th_percentile":1099.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":2433.72,"10th_percentile":2433.72,"90th_percentile":2433.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":322.49,"10th_percentile":322.49,"90th_percentile":322.49,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"1 through 10","median_amount":2553.01,"10th_percentile":2553.01,"90th_percentile":2553.01,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":1179.9,"10th_percentile":1179.9,"90th_percentile":1179.9,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":745.72,"10th_percentile":745.72,"90th_percentile":745.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2276.84,"10th_percentile":2276.84,"90th_percentile":2276.84,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1312.46,"10th_percentile":1312.46,"90th_percentile":1312.46,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":2340.21,"10th_percentile":2340.21,"90th_percentile":2615.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":402.21,"10th_percentile":314.88,"90th_percentile":553.64,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Diagnostic Tests and Related Services","code_information":[{"code":"5724","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":6083.35,"10th_percentile":6083.35,"90th_percentile":6344.59,"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":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":2171.79,"10th_percentile":1947.39,"90th_percentile":2374.46,"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":"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"32","median_amount":4892.0,"10th_percentile":2570.0,"90th_percentile":5140.0,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"23","median_amount":4589.0,"10th_percentile":3071.2,"90th_percentile":4589.0,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":6221.61,"10th_percentile":6129.62,"90th_percentile":6488.78,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"1 through 10","median_amount":5799.92,"10th_percentile":5799.92,"90th_percentile":5799.92,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":4938.57,"10th_percentile":4938.57,"90th_percentile":5150.65,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"23","median_amount":2121.57,"10th_percentile":2032.39,"90th_percentile":2262.68,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1249.06,"10th_percentile":1249.06,"90th_percentile":1282.41,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"23","median_amount":1249.06,"10th_percentile":1249.06,"90th_percentile":1282.41,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":519.1,"10th_percentile":519.1,"90th_percentile":519.1,"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":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":3719.3,"10th_percentile":3719.3,"90th_percentile":3965.37,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"35","median_amount":5405.89,"10th_percentile":4510.42,"90th_percentile":5638.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"36","median_amount":2073.87,"10th_percentile":1730.34,"90th_percentile":2307.12,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Minor Procedures","code_information":[{"code":"5731","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":1481.86,"10th_percentile":1481.86,"90th_percentile":1481.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":1155.59,"10th_percentile":642.0,"90th_percentile":1224.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"11","median_amount":612.0,"10th_percentile":286.0,"90th_percentile":1608.0,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":502.39,"10th_percentile":502.39,"90th_percentile":502.39,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":1009.82,"10th_percentile":1009.82,"90th_percentile":1009.82,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":1078.28,"10th_percentile":539.14,"90th_percentile":2016.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":553.89,"10th_percentile":175.07,"90th_percentile":1059.34,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":283.32,"10th_percentile":212.49,"90th_percentile":708.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":5.0,"10th_percentile":5.0,"90th_percentile":5.0,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":48.63,"10th_percentile":48.63,"90th_percentile":138.37,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":198.36,"10th_percentile":66.32,"90th_percentile":282.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":167.91,"10th_percentile":55.97,"90th_percentile":223.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":12659.76,"10th_percentile":12659.76,"90th_percentile":12659.76,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":363.42,"10th_percentile":121.14,"90th_percentile":423.99,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":443.34,"10th_percentile":251.9,"90th_percentile":1330.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"28","median_amount":353.9,"10th_percentile":73.77,"90th_percentile":653.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"12","median_amount":278.94,"10th_percentile":124.82,"90th_percentile":811.16,"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 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"12","median_amount":130.22,"10th_percentile":115.87,"90th_percentile":303.3,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":303.08,"10th_percentile":303.08,"90th_percentile":303.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2340.86,"10th_percentile":2340.86,"90th_percentile":2340.86,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"18","median_amount":371.09,"10th_percentile":79.4,"90th_percentile":747.73,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":109.93,"10th_percentile":109.93,"90th_percentile":109.93,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":100.99,"10th_percentile":42.33,"90th_percentile":218.58,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":929.88,"10th_percentile":929.88,"90th_percentile":929.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"13","median_amount":1216.69,"10th_percentile":301.85,"90th_percentile":2218.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"53","median_amount":484.56,"10th_percentile":80.61,"90th_percentile":680.13,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":593.32,"10th_percentile":300.77,"90th_percentile":2295.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":1053.22,"10th_percentile":797.81,"90th_percentile":1597.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"16","median_amount":130.82,"10th_percentile":40.48,"90th_percentile":242.52,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"16","median_amount":87.81,"10th_percentile":21.11,"90th_percentile":202.75,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":573.2,"10th_percentile":311.56,"90th_percentile":3160.96,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2394.15,"10th_percentile":2394.15,"90th_percentile":2394.15,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":787.33,"10th_percentile":335.38,"90th_percentile":43627.02,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":101.78,"10th_percentile":27.11,"90th_percentile":194.5,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"25","median_amount":37.51,"10th_percentile":18.25,"90th_percentile":200.02,"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":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":73.18,"10th_percentile":35.25,"90th_percentile":98.72,"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":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"56","median_amount":488.16,"10th_percentile":280.0,"90th_percentile":1952.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"13","median_amount":768.32,"10th_percentile":215.57,"90th_percentile":7586.73,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 5 Minor Procedures","code_information":[{"code":"5735","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":311.34,"10th_percentile":311.34,"90th_percentile":311.34,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":2053.68,"10th_percentile":254.68,"90th_percentile":3765.08,"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":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":522.27,"10th_percentile":222.26,"90th_percentile":853.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":1708.0,"10th_percentile":244.0,"90th_percentile":2928.0,"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":691.01,"10th_percentile":406.0,"90th_percentile":1491.0,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2176.66,"10th_percentile":2176.66,"90th_percentile":3843.88,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"18","median_amount":762.37,"10th_percentile":418.29,"90th_percentile":1309.32,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":777.91,"10th_percentile":111.13,"90th_percentile":1367.2,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1221.5,"10th_percentile":244.3,"90th_percentile":3420.2,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":178.28,"10th_percentile":178.28,"90th_percentile":178.28,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"11","median_amount":1357.9,"10th_percentile":150.0,"90th_percentile":1855.8,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"31","median_amount":711.2,"10th_percentile":222.26,"90th_percentile":1380.83,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Resuscitation and Cardioversion","code_information":[{"code":"5781","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":4607.99,"10th_percentile":4607.99,"90th_percentile":4607.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3037.29,"10th_percentile":3037.29,"90th_percentile":3037.29,"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":2568.0,"10th_percentile":2568.0,"90th_percentile":2568.0,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pulmonary Treatment","code_information":[{"code":"5791","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":113.01,"10th_percentile":113.01,"90th_percentile":113.01,"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":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":261.27,"10th_percentile":261.27,"90th_percentile":261.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":256.16,"10th_percentile":256.16,"90th_percentile":256.16,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":94.47,"10th_percentile":94.47,"90th_percentile":94.47,"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":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":21.38,"10th_percentile":21.38,"90th_percentile":21.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inj, denosumab","code_information":[{"code":"9272","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":1920.17,"10th_percentile":1920.17,"90th_percentile":1920.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem 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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Platelets, pheresis","code_information":[{"code":"9507","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":3323.95,"10th_percentile":3323.95,"90th_percentile":3323.95,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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 ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): 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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":155.59,"10th_percentile":138.92,"90th_percentile":167.85,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":121.67,"10th_percentile":121.67,"90th_percentile":121.67,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"144","median_amount":380.93,"10th_percentile":122.25,"90th_percentile":1115.0,"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":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"858","median_amount":132.87,"10th_percentile":38.41,"90th_percentile":336.14,"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. 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Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"776","median_amount":53.63,"10th_percentile":19.85,"90th_percentile":172.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":"730","median_amount":52.42,"10th_percentile":18.33,"90th_percentile":172.27,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"133","median_amount":449.49,"10th_percentile":140.03,"90th_percentile":1154.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"16","median_amount":638.19,"10th_percentile":141.54,"90th_percentile":2223.7,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"107","median_amount":370.42,"10th_percentile":87.49,"90th_percentile":1508.24,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1134","median_amount":132.07,"10th_percentile":36.67,"90th_percentile":317.33,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"232","median_amount":28.18,"10th_percentile":5.29,"90th_percentile":140.37,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"24","median_amount":106.05,"10th_percentile":42.26,"90th_percentile":248.1,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1206","median_amount":36.26,"10th_percentile":8.44,"90th_percentile":176.63,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"26","median_amount":16.43,"10th_percentile":3.09,"90th_percentile":50.23,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"30","median_amount":27.5,"10th_percentile":4.91,"90th_percentile":102.95,"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":"Molina Healthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":111.71,"10th_percentile":109.43,"90th_percentile":111.71,"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":"Multiplan","plan_name":"Healtheos 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":404.78,"10th_percentile":298.82,"90th_percentile":414.42,"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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"68","median_amount":76.44,"10th_percentile":36.22,"90th_percentile":333.17,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1932","median_amount":390.56,"10th_percentile":115.37,"90th_percentile":1083.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":29.8,"10th_percentile":8.03,"90th_percentile":176.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1929","median_amount":151.23,"10th_percentile":36.74,"90th_percentile":359.0,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"1 through 10","median_amount":186.68,"10th_percentile":186.68,"90th_percentile":309.12,"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 Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"1 through 10","median_amount":884.75,"10th_percentile":884.75,"90th_percentile":884.75,"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."}]}]},{"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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"67","median_amount":399.79,"10th_percentile":308.54,"90th_percentile":1034.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"149","median_amount":209.05,"10th_percentile":117.08,"90th_percentile":733.96,"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 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 ($): FEE SCHEDULE] [OP Surg. 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Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"398","median_amount":321.0,"10th_percentile":256.8,"90th_percentile":1284.0,"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. 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Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":"287","median_amount":268.0,"10th_percentile":236.97,"90th_percentile":1284.0,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"34","median_amount":1213.46,"10th_percentile":541.05,"90th_percentile":2661.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"1 through 10","median_amount":411.82,"10th_percentile":411.82,"90th_percentile":446.37,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"44","median_amount":383.45,"10th_percentile":339.04,"90th_percentile":1544.85,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"346","median_amount":182.23,"10th_percentile":123.13,"90th_percentile":742.71,"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":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":251.61,"10th_percentile":251.61,"90th_percentile":251.61,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":146.36,"10th_percentile":106.53,"90th_percentile":598.36,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":161.0,"10th_percentile":39.06,"90th_percentile":329.1,"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":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"12","median_amount":299.18,"10th_percentile":299.18,"90th_percentile":342.27,"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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":552.57,"10th_percentile":552.57,"90th_percentile":762.6,"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":"Standard Network All Commercial Plans","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":"56","median_amount":438.91,"10th_percentile":248.0,"90th_percentile":1104.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"413","median_amount":540.28,"10th_percentile":317.49,"90th_percentile":1681.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"532","median_amount":174.46,"10th_percentile":120.26,"90th_percentile":761.88,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"1 through 10","median_amount":413.29,"10th_percentile":381.58,"90th_percentile":2690.52,"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 Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mammography Services","code_information":[{"code":"N804","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"43","median_amount":1064.32,"10th_percentile":1064.32,"90th_percentile":1064.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"104","median_amount":379.28,"10th_percentile":379.28,"90th_percentile":379.28,"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":"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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"254","median_amount":571.82,"10th_percentile":546.82,"90th_percentile":571.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":"328","median_amount":500.82,"10th_percentile":479.82,"90th_percentile":500.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"40","median_amount":1088.5,"10th_percentile":1088.5,"90th_percentile":1088.5,"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":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"1 through 10","median_amount":1014.73,"10th_percentile":1014.73,"90th_percentile":1014.73,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"42","median_amount":864.03,"10th_percentile":864.03,"90th_percentile":864.03,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"163","median_amount":355.59,"10th_percentile":355.59,"90th_percentile":379.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":114.39,"10th_percentile":114.39,"90th_percentile":116.09,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":362.84,"10th_percentile":362.84,"90th_percentile":419.2,"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":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"108","median_amount":114.39,"10th_percentile":114.39,"90th_percentile":116.09,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":46.02,"10th_percentile":46.02,"90th_percentile":47.04,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":114.39,"10th_percentile":114.39,"90th_percentile":120.74,"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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":864.03,"10th_percentile":700.2,"90th_percentile":967.56,"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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"50","median_amount":665.2,"10th_percentile":577.75,"90th_percentile":665.2,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"353","median_amount":945.79,"10th_percentile":945.79,"90th_percentile":945.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"281","median_amount":164.7,"10th_percentile":164.69,"90th_percentile":168.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"1 through 10","median_amount":1028.54,"10th_percentile":1028.54,"90th_percentile":1028.54,"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":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Durable Medical Equipment","code_information":[{"code":"N805","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":159.49,"10th_percentile":159.49,"90th_percentile":159.49,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Medicine","code_information":[{"code":"N809","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":1424.3,"10th_percentile":1424.3,"90th_percentile":1424.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":217.2,"10th_percentile":217.2,"90th_percentile":217.2,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-covered Services","code_information":[{"code":"N900","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Access Ppo/Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"24","median_amount":123.67,"10th_percentile":72.86,"90th_percentile":642.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":88.07,"10th_percentile":52.19,"90th_percentile":1020.0,"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":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":498.24,"10th_percentile":485.11,"90th_percentile":2394.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"1 through 10","median_amount":564.26,"10th_percentile":564.26,"90th_percentile":564.26,"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":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":480.46,"10th_percentile":480.46,"90th_percentile":480.46,"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":"Humana","plan_name":"Advantage Medicare Managed Care - Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":43.35,"10th_percentile":43.35,"90th_percentile":43.35,"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":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":354.71,"10th_percentile":341.77,"90th_percentile":886.89,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"21","median_amount":496.3,"10th_percentile":363.69,"90th_percentile":770.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","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":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":229.94,"10th_percentile":229.94,"90th_percentile":229.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"1 through 10","median_amount":72.03,"10th_percentile":72.03,"90th_percentile":72.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":48.1,"10th_percentile":48.1,"90th_percentile":60.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":48.1,"10th_percentile":48.1,"90th_percentile":48.1,"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":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":235.17,"10th_percentile":235.17,"90th_percentile":235.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":29.16,"10th_percentile":20.81,"90th_percentile":29.16,"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":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8.4,"10th_percentile":8.4,"90th_percentile":54.91,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":124.82,"10th_percentile":124.82,"90th_percentile":124.82,"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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":199.66,"10th_percentile":180.2,"90th_percentile":204.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"1 through 10","median_amount":78.39,"10th_percentile":78.39,"90th_percentile":78.39,"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":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Not Recognized by OPPS","code_information":[{"code":"N905","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 88] [OP Surgery  (%BC): 88] [Observation (%BC): 88] [Emergency Department (%BC): 88] [Occupational Therapy (%BC): 88] [Physical Therapy (%BC): 88] [Respiratory Services/Therapy  (%BC): 88] [Speech Therapy (%BC): 88] [All Other OP (%BC): 88]","count":"1 through 10","median_amount":12018.24,"10th_percentile":12018.24,"90th_percentile":12018.24,"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":"Advantage Medicare Managed Care - Hmo/Ppo","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 10821] [Ablation ($): 65406] [Cardiac Cath ($): 22373] [Lithotripsy ($): 29767] [PTCA ($): 42105] [Observation ($): 12759] [ED Level 1--99281 ($): 779] [ED Level 2--99282 ($): 779] [ED Level 3--99283 ($): 2456] [ED Level 4--99284 ($): 4746] [ED Level 5--99285 ($): 4746] [Critical Care-99291 ($): 11578] [Urgent Care ($): 700] [Cardiac Rehabilitation Therapy ($): 251] [Electrophysiology and Mapping Studies ($): 65406] [Sleep Studies-Attended ($): 5294] [Sleep Studies-Unattended ($): 1513] [CT Scan OP ($): 3529] [MRI OP ($): 4386] [Mammography-Diagnostic ($): 529] [Mammography-Screening ($): 529] [Positron Emission Tomography ($): 6855] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 946] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 331] [Physical Therapy ($): 331] [Resp. Services/Therapy ($): 251] [Speech Therapy ($): 331] [Mental Health (%BC): 50] [OP ECT Mental Health (%BC): 46] [Other Pharmacy ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 46] [Ambulance--Air  (%BC): 46] [IV Therapy (%BC): 55] [All Other OP (%BC): 46]","count":"1 through 10","median_amount":4321.7,"10th_percentile":4100.78,"90th_percentile":4322.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Blue Preferred/Blue Preferred Plus Hmo/Pos","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): 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 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 7599] [Ablation ($): 56399] [Cardiac Cath ($): 19301] [Lithotripsy ($): 25903] [PTCA ($): 36305] [Observation ($): 11707] [ED Level 1--99281 ($): 703] [ED Level 2--99282 ($): 703] [ED Level 3--99283 ($): 2047] [ED Level 4--99284 ($): 3934] [ED Level 5--99285 ($): 3934] [Critical Care-99291 ($): 10937] [Urgent Care ($): 544] [Cardiac Rehabilitation Therapy ($): 219] [Electrophysiology and Mapping Studies ($): 56399] [Sleep Studies-Attended ($): 4727] [Sleep Studies-Unattended ($): 1262] [CT Scan OP ($): 2913] [MRI OP ($): 3790] [Mammography-Diagnostic ($): 456] [Mammography-Screening ($): 456] [Positron Emission Tomography ($): 5187] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 788] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 46] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 46] [Occupational Therapy ($): 276] [Physical Therapy ($): 276] [Resp. Services/Therapy ($): 219] [Speech Therapy ($): 276] [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":3728.72,"10th_percentile":2424.94,"90th_percentile":3740.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 90] [OP Surgery  (%BC): 90] [Observation (%BC): 90] [Emergency Department (%BC): 90] [Occupational Therapy (%BC): 90] [Physical Therapy (%BC): 90] [Respiratory Services/Therapy  (%BC): 90] [Speech Therapy (%BC): 90] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":11949.71,"10th_percentile":11949.71,"90th_percentile":12493.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Dean Health Plan","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 43.18] [OP Surgery  (%BC): 43.18] [Observation (%BC): 43.18] [Emergency Department (%BC): 43.18] [Occupational Therapy (%BC): 43.18] [Physical Therapy (%BC): 43.18] [Respiratory Services/Therapy  (%BC): 43.18] [Speech Therapy (%BC): 43.18] [All Other OP (%BC): 43.18]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 76] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [All Other OP (%BC): 76]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Icare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":656.47,"10th_percentile":656.47,"90th_percentile":656.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Icare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mercycare","plan_name":"Badgercare Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":656.47,"10th_percentile":656.47,"90th_percentile":660.41,"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":"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://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Molina Healthcare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_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): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Healtheos 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":"My Choice","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28] [OP Surgery  (%BC): 28] [Observation (%BC): 28] [Emergency Department (%BC): 28] [Occupational Therapy (%BC): 28] [Physical Therapy (%BC): 28] [Respiratory Services/Therapy  (%BC): 28] [Speech Therapy (%BC): 28] [All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"Standard Network All Commercial Plans","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":"Trilogy Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 85] [OP Surgery  (%BC): 85] [Observation (%BC): 85] [Emergency Department (%BC): 85] [Occupational Therapy (%BC): 85] [Physical Therapy (%BC): 85] [Respiratory Services/Therapy  (%BC): 85] [Speech Therapy (%BC): 85] [All Other OP (%BC): 85]","count":"0","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): 78.2] [Observation (%BC): 78.2] [Emergency Department (%BC): 78.2] [Occupational Therapy (%BC): 78.2] [Physical Therapy (%BC): 78.2] [Respiratory Services/Therapy  (%BC): 78.2] [Speech Therapy (%BC): 78.2] [All Other OP (%BC): 78.2]","count":"1 through 10","median_amount":10855.51,"10th_percentile":6272.88,"90th_percentile":10855.51,"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":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 28]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physicians Service","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 75.53] [Observation (%BC): 75.53] [Emergency Department (%BC): 75.53] [Radiology Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75.53] [Physical Therapy (%BC): 75.53] [Respiratory Services/Therapy  (%BC): 75.53] [Speech Therapy (%BC): 75.53] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 75.53]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Zing Health Provider Network","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[All OP services (%BC): 28.84] [OP Surgery  (%BC): 28.84] [Observation (%BC): 28.84] [Emergency Department (%BC): 28.84] [Occupational Therapy (%BC): 28.84] [Physical Therapy (%BC): 28.84] [Respiratory Services/Therapy  (%BC): 28.84] [Speech Therapy (%BC): 28.84] [All Other OP (%BC): 28.84]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]}]}